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Reilly C, Jette N, Johnson EC, Kariuki SM, Meredith F, Wirrell E, Mula M, Smith ML, Walsh S, Fong CY, Wilmshurst JM, Kerr M, Valente K, Auvin S. 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. Epilepsia 2023; 64:3160-3195. [PMID: 37804168 DOI: 10.1111/epi.17768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 10/09/2023]
Abstract
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.
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Affiliation(s)
- Colin Reilly
- Research Department, Young Epilepsy, Lingfield, UK
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinia, New York City, New York, USA
| | | | - Symon M Kariuki
- KEMRI-Wellcome Trust Research Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Public Health, Pwani University, Kilifi, Kenya
| | | | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marco Mula
- IMBE, St George's University and the Atkinson Morley Regional Neuroscience Centre, St George's University Hospital, London, UK
| | - Mary Lou Smith
- Department of Psychology, University of Toronto Mississauga and Neurosciences and Mental Health Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Samantha Walsh
- Levy Library, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Choong Yi Fong
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Mike Kerr
- Institute of Psychological Medicine and Clinical Neurosciences Cardiff University, Cardiff, UK
| | - Kette Valente
- Clinical Neurophysiology Sector, University of São Paulo, Clinic Hospital (HCFMUSP), São Paulo, Brazil
| | - Stephane Auvin
- Université Paris Cité, INSERM NeuroDiderot, Paris, France
- Pediatric Neurology Department, APHP, Robert Debré University Hospital, CRMR epilepsies rares, EpiCare member, Paris, France
- Institut Universitaire de France (IUF), Paris, France
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Milano BA, Moutoussis M, Convertino L. The neurobiology of functional neurological disorders characterised by impaired awareness. Front Psychiatry 2023; 14:1122865. [PMID: 37009094 PMCID: PMC10060839 DOI: 10.3389/fpsyt.2023.1122865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 02/24/2023] [Indexed: 03/18/2023] Open
Abstract
We review the neurobiology of Functional Neurological Disorders (FND), i.e., neurological disorders not explained by currently identifiable histopathological processes, in order to focus on those characterised by impaired awareness (functionally impaired awareness disorders, FIAD), and especially, on the paradigmatic case of Resignation Syndrome (RS). We thus provide an improved more integrated theory of FIAD, able to guide both research priorities and the diagnostic formulation of FIAD. We systematically address the diverse spectrum of clinical presentations of FND with impaired awareness, and offer a new framework for understanding FIAD. We find that unraveling the historical development of neurobiological theory of FIAD is of paramount importance for its current understanding. Then, we integrate contemporary clinical material in order to contextualise the neurobiology of FIAD within social, cultural, and psychological perspectives. We thus review neuro-computational insights in FND in general, to arrive at a more coherent account of FIAD. FIAD may be based on maladaptive predictive coding, shaped by stress, attention, uncertainty, and, ultimately, neurally encoded beliefs and their updates. We also critically appraise arguments in support of and against such Bayesian models. Finally, we discuss implications of our theoretical account and provide pointers towards an improved clinical diagnostic formulation of FIAD. We suggest directions for future research towards a more unified theory on which future interventions and management strategies could be based, as effective treatments and clinical trial evidence remain limited.
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Affiliation(s)
- Beatrice Annunziata Milano
- Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
- Faculty of Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Michael Moutoussis
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- Max Planck UCL Centre for Computational Psychiatry and Ageing Research, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
| | - Laura Convertino
- Wellcome Centre for Human Neuroimaging, University College London, London, United Kingdom
- National Hospital of Neurology and Neurosurgery (UCLH), London, United Kingdom
- Institute of Cognitive Neuroscience, University College London, London, United Kingdom
- *Correspondence: Laura Convertino,
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Soe KC, Lopez WL. Clinical progress note: Management of somatic symptom and related disorders in pediatric inpatients. J Hosp Med 2022; 17:996-999. [PMID: 36000278 PMCID: PMC10087315 DOI: 10.1002/jhm.12947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 07/27/2022] [Accepted: 08/05/2022] [Indexed: 12/15/2022]
Affiliation(s)
- Katherine C Soe
- Division of Hospital Medicine/Division of Child & Adolescent Psychiatry, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, College of Medicine, University of Cincinnati, Cincinnati, Ohio, USA
| | - Wendi L Lopez
- Division of Behavioral Medicine & Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
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Stigma in Functional Seizures: A Scoping Review. Seizure 2022; 99:131-152. [DOI: 10.1016/j.seizure.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 11/18/2022] Open
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Freedman D. Functional Neurological Disorders in Children - A Historical Perspective. Semin Pediatr Neurol 2022; 41:100950. [PMID: 35450665 DOI: 10.1016/j.spen.2021.100950] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2021] [Revised: 12/28/2021] [Accepted: 12/29/2021] [Indexed: 11/16/2022]
Abstract
The modern diagnosis of functional neurological disorders (FND) describes a diverse set of neurological symptoms without identifiable pathology. The history of FND and its prescientific predecessor, hysteria, is complex and deeply rooted in sexism. Key moments in this history have contributed to the advancement of understanding in functional disorders that neurologists should be aware of. Although pediatric FND has a much less extensive historical literature, there are many parallels between it and the initial interest in hysteria by Charcot and other early modern neurologists. This was followed by waning neurological attention as psychiatrists promoted conversion disorder in the early 1900s. Towards the end of the 20th century, neurologists have taken a renewed, collaborative role with psychiatry and other disciplines to diagnose and study FND.
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What do patients prefer their functional seizures to be called, and what are their experiences of diagnosis? - A mixed methods investigation. Epilepsy Behav 2021; 117:107817. [PMID: 33621810 DOI: 10.1016/j.yebeh.2021.107817] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/21/2021] [Accepted: 01/21/2021] [Indexed: 11/21/2022]
Abstract
This study explored the preferred terms for functional seizures, and the experience of being diagnosed, from the patient's perspective. 39 patients in a neuropsychiatry service diagnosed with functional seizures completed an online survey to investigate preferences for, and offensiveness of, 11 common diagnostic terms used to describe functional seizures. Of these 39 patients, 13 consented to take part in a semistructured interview exploring the experience of receiving a diagnosis. Nonepileptic attack disorder (NEAD), functional seizures, functional nonepileptic attacks (FNEA), and dissociative seizures were ranked the highest preferred terms and did not significantly differ from one another. NEAD was the least offensive term, with functional seizures and FNEA following closely. Significant overlap in confidence intervals was found between the offensiveness of all terms. Terms that indicated a psychological origin were the least preferred and viewed as most offensive. Thematic analysis identified three main themes on the experience of being diagnosed: 'being heard and having a shared understanding', 'feeling alone', and 'sense of hope'. Patients favored diagnostic terms that facilitated and alleviated these themes on a personal basis; however, preferences differed across individuals. Our findings suggest that a range of terms have a similar level of preference and offense rating, with NEAD, functional seizures, and FNEA being the most favorable. Qualitative analysis indicates that a term and its accompanying explanation should facilitate shared acceptance and understanding, and several terms provide this. In combination with our previous study on healthy participants, we propose that one of the two terms researched are adopted by patients, health professionals, and the public: Functional nonepileptic attacks or Functional seizures.
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Abstract
Functional or psychogenic seizures have proved a diagnostic and therapeutic challenge for centuries. Functional seizures can look and feel similar to epileptic seizures but are instead a common and highly disabling form of functional neurologic disorder, or conversion disorder. Consistent with the biopsychosocial model of mental illness, functional seizures are caused by biological, psychological, and social factors unrelated to epileptic discharges. People with functional seizures do not consciously fake their symptoms. Functional seizures can be differentiated from epileptic seizures through the clinical history, features of the seizures themselves, and electroencephalography findings. Psychotherapy is effective in treating functional seizures.
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Goleva SB, Lake AM, Torstenson ES, Haas KF, Davis LK. Epidemiology of Functional Seizures Among Adults Treated at a University Hospital. JAMA Netw Open 2020; 3:e2027920. [PMID: 33372972 PMCID: PMC7772716 DOI: 10.1001/jamanetworkopen.2020.27920] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Accepted: 10/08/2020] [Indexed: 12/28/2022] Open
Abstract
Importance Functional seizures (formerly psychogenic nonepileptic seizures), paroxysmal episodes that are often similar to epileptic seizures in their clinical presentation and display no aberrant brain electrical patterns, are understudied. Patients experience a long diagnostic delay, few treatment modalities, a high rate of comorbidities, and significant stigma due to the lack of knowledge about functional seizures. Objective To characterize the clinical epidemiology of a population of patients with functional seizures observed at Vanderbilt University Medical Center (VUMC). Design, Setting, and Participants This case-control study included patients with functional seizures identified in the VUMC electronic health record (VUMC-EHR) system from October 1989 to October 2018. Patients with epilepsy were excluded from the study and all remaining patients in the VUMC medical center system were used as controls. In total, the study included 1431 patients diagnosed with functional seizures, 2251 with epilepsy and functional seizures, 4715 with epilepsy without functional seizures, and 502 200 control patients who received treatment at VUMC for a minimum of a 3 years. Data were analyzed from November 2018 to March 2020. Exposure Diagnosis of functional seizures, as identified from the VUMC-EHR system by an automated phenotyping algorithm that incorporated International Classification of Diseases, Ninth Revision (ICD-9) codes, International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) codes, Current Procedural Terminology codes, and natural language processing. Main Outcomes and Measures Associations of functional seizures with comorbidities and risk factors, measured in odds ratios (ORs). Results Of 2 346 808 total patients in the VUMC-EHR aged 18 years or older, 3341 patients with functional seizures were identified (period prevalence, 0.14%), 1062 (74.2%) of whom were women and for which the median (interquartile range) age was 49.3 (39.4-59.9) years. This assessment replicated previously reported associations with psychiatric disorders including posttraumatic stress disorder (PTSD) (OR, 1.22; 95% CI, 1.21-1.24; P < 3.02 × 10-5), anxiety (OR, 1.14; 95% CI, 1.13-1.15; P < 3.02 × 10-5), and depression (OR, 1.14; 95% CI, 1.13-1.15; P < 3.02 × 10-5), and identified novel associations with cerebrovascular disease (OR, 1.08; 95% CI, 1.06-1.09; P < 3.02 × 10-5). An association was found between functional seizures and the known risk factor sexual assault trauma (OR, 10.26; 95% CI, 10.09-10.44; P < 3.02 × 10-5), and sexual assault trauma was found to mediate nearly a quarter of the association between female sex and functional seizures in the VUMC-EHR. Conclusions and Relevance This case-control study found evidence to support previously reported associations, discovered new associations between functional seizures and PTSD, anxiety, and depression. An association between cerebrovascular disease and functional seizures was also found. Results suggested that sexual trauma may be a mediating factor in the association between female sex and functional seizures.
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Affiliation(s)
- Slavina B. Goleva
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
| | - Allison M. Lake
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Eric S. Torstenson
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Division of Epidemiology, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Epidemiology Center, Institute for Medicine and Public Health, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kevin F. Haas
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lea K. Davis
- Division of Genetic Medicine, Department of Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
- Vanderbilt Genetics Institute, Vanderbilt University Medical Center, Nashville, Tennessee
- Department of Molecular Physiology and Biophysics, Vanderbilt University, Nashville, Tennessee
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Abstract
Placebos impact epilepsy in a number of ways. Through randomized clinical trials, explicit clinical use, and also through implicit clinical use, placebos play a role in epilepsy. This chapter will discuss the reasons placebo is used, the determinants of placebo response in epilepsy, observations about placebo specific to epilepsy, and ways in which clinical trial design is impacted by placebo.
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We need a functioning name for PNES: Consider dissociative seizures. Epilepsy Behav 2020; 105:107002. [PMID: 32160585 DOI: 10.1016/j.yebeh.2020.107002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2020] [Revised: 02/19/2020] [Accepted: 02/20/2020] [Indexed: 11/21/2022]
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Terminology for psychogenic nonepileptic seizures: Making the case for "functional seizures". Epilepsy Behav 2020; 104:106895. [PMID: 31986440 DOI: 10.1016/j.yebeh.2019.106895] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 12/28/2019] [Accepted: 12/29/2019] [Indexed: 01/28/2023]
Abstract
PURPOSE The purpose of the study was to review the literature on the terminologies for psychogenic nonepileptic seizures (PNES) and make a proposal on the terminology of this condition. This proposal reflects the authors' own opinions. METHODS We systematically searched MEDLINE (accessed from PubMed) and EMBASE from inception to October 10, 2019 for articles written in English with a main focus on PNES (with or without discussion of other functional neurological disorders) and which either proposed or discussed the accuracy or appropriateness of PNES terminologies. RESULTS The search strategy reported above yielded 757 articles; 30 articles were eventually included, which were generally of low quality. "Functional seizures" (FS) appeared to be an acceptable terminology to name this condition from the perspective of patients. In addition, FS is a term that is relatively popular with clinicians. CONCLUSION From the available evidence, FS meets more of the criteria proposed for an acceptable label than other popular terms in the field. While the term FS is neutral with regard to etiology and pathology (particularly regarding whether psychological or not), other terms such as "dissociative", "conversion", or "psychogenic" seizures are not. In addition, FS can potentially facilitate multidisciplinary (physical and psychological) management more than other terms. Adopting a universally accepted terminology to describe this disorder could standardize our approach to the illness and facilitate communication between healthcare professionals, patients, their families, carers, and the wider public.
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Patient and family perspectives of paediatric psychogenic non-epileptic seizures: A systematic review. Seizure 2019; 71:279-285. [PMID: 31493680 DOI: 10.1016/j.seizure.2019.08.014] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Revised: 08/24/2019] [Accepted: 08/28/2019] [Indexed: 11/22/2022] Open
Abstract
Exploring the perspectives of those affected by psychogenic non-epileptic seizures (PNES) may be essential in learning more about the nature of this condition. The aim of this systematic review is to synthesise the evidence regarding the perspectives of children and adolescents with PNES, and the perspectives of their parents, caregivers and families. Studies were included if they (1) explored PNES in a paediatric population, (2) explored the perspectives of the child or adolescent with PNES, or the perspectives of their parents, caregivers or families, (3) were original research, and (4) were written in the English language. Eight studies were identified for inclusion following searching of CINAHL Complete, Medline (Ovid), PsycINFO, PubMed and Web of Science databases, along with additional hand searching of reference lists. Quality assessment of articles was conducted using the Critical Appraisal Skills Programme (CASP) qualitative checklist. Seven articles were deemed high quality, and one article was deemed moderate quality. Common threads across studies included: "legitimacy and the importance of understanding", "distress and the social and emotional impact of PNES" and "moving forward". Clinicians must take care in the delivery of the diagnosis; including the use of an appropriate name for this condition, and providing an explanation of PNES that is acceptable to the patient, as well as ensuring that follow-up support is provided. Further reviews are required that utilise more well-established quality appraisal scoring systems and with the inclusion of grey literature, which refers to evidence not published by commercial academic publishers.
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Yogarajah M, Child R, Agrawal N, Cope S, Edwards M, Mula M. Functional seizures: An evaluation of the attitudes of general practitioners local to a tertiary neuroscience service in London. Epilepsia Open 2019; 4:54-62. [PMID: 30868115 PMCID: PMC6398091 DOI: 10.1002/epi4.12283] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Revised: 09/17/2018] [Accepted: 10/17/2018] [Indexed: 12/04/2022] Open
Abstract
OBJECTIVE Functional seizures are a common functional neurologic disorder. Given their chronic nature, and the biopsychosocial factors involved in their etiology, general practitioners (GPs) play a crucial role in the care of these patients. However, little is known about the attitudes of GPs toward, and knowledge of, functional seizures. METHODS The Atkinson Morley Regional Neuroscience Centre in London provides a comprehensive service to patients with functional seizures. As part of a service evaluation we conducted an online survey among local GPs over a 1-month period assessing their attitudes toward, and knowledge of, functional seizures. RESULTS One hundred twenty of 974 surveyed GPs replied to the survey (12.3%). Approximately 75% of GPs readily use the term "pseudoseizures," and over 50% were not sure or did not think that functional seizures were involuntary. Nearly 30% believed, or were unsure as to whether, functional seizures occur only when patients are stressed. Despite approximately 50% of GPs expressing interest in getting involved in the management of these patients, a similar proportion do not feel confident in dealing with queries from patients with functional seizures. Although most GPs felt that neurology and psychiatry should be the primary caregivers in the diagnosis and management, respectively, of functional seizures, 50% were also of the opinion that neurology should be involved in the management of these patients. SIGNIFICANCE This survey highlights the attitudes of, and descriptive terms used by, GPs toward patients with functional seizures. Our findings suggest a need for better and clearer provision of information to GPs about this condition.
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Affiliation(s)
- Mahinda Yogarajah
- Atkinson Morley Regional Neuroscience CentreSt George's University Hospitals NHS Foundation TrustLondonUK
- Institute of Molecular and Clinical SciencesSt George's University of LondonLondonUK
| | - Ruth Child
- Medical SchoolSt George's University of LondonLondonUK
| | - Niruj Agrawal
- Atkinson Morley Regional Neuroscience CentreSt George's University Hospitals NHS Foundation TrustLondonUK
- Department of NeuropsychiatrySouth West London & St George's Mental Health TrustLondonUK
| | - Sarah Cope
- Department of NeuropsychiatrySouth West London & St George's Mental Health TrustLondonUK
| | - Mark Edwards
- Atkinson Morley Regional Neuroscience CentreSt George's University Hospitals NHS Foundation TrustLondonUK
- Institute of Molecular and Clinical SciencesSt George's University of LondonLondonUK
| | - Marco Mula
- Atkinson Morley Regional Neuroscience CentreSt George's University Hospitals NHS Foundation TrustLondonUK
- Institute of Medical and Biomedical EducationSt George's University of LondonLondonUK
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Nielsen ES, Wichaidit BT, Østergaard JR, Rask CU. Paediatricians' attitudes to and management of functional seizures in children. Eur J Paediatr Neurol 2018; 22:774-781. [PMID: 29871800 DOI: 10.1016/j.ejpn.2018.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/04/2018] [Accepted: 05/20/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To explore paediatricians' attitudes to and treatment practice for children with functional seizures (FS). METHODS In a nationwide survey, all 64 Danish neuro-paediatricians and social paediatricians were invited to complete a structured questionnaire encompassing FS-related issues that included beliefs and attitudes about aetiology and diagnostic assessment, current strategies for management, experienced need for clinical guidelines and better treatment options. RESULTS A total of 61 paediatricians (95%) participated in the study. Nearly half (46%) had seen more than 30 children with FS during their career. Most (65%) believed in a primarily psychogenic aetiology. More than half (57%) stated that they could make the diagnosis by solely observing a seizure, and 18% indicated the children faked their symptoms. The paediatricians' responses to these issues did not significantly vary according to their level of clinical experience. Furthermore, the majority (78%) expressed a need for clinical guidelines, and only 13% rated existing treatment options as sufficient. Collaborative care between different specialties or management in a child and adolescent mental health services (CAMHS) setting was seen as the best model for treatment. However, only 23% reported often referring these children to CAMHS after making the diagnosis. CONCLUSION The findings suggest that introduction of clinical guidelines in this area is highly needed. Such guidelines could promote more formal training of paediatricians in understanding and assessing FS and increased collaboration between paediatrics and CAMHS regarding care for children with this challenging and potentially costly and disabling disorder.
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Affiliation(s)
| | - Bianca Taaning Wichaidit
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
| | | | - Charlotte Ulrikka Rask
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark; Child and Adolescent Psychiatric Centre, Aarhus University Hospital, Risskov, Denmark
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Non-epileptic seizures in children: Views and approaches at a UK child and adolescent psychiatry conference. Seizure 2017; 53:23-25. [DOI: 10.1016/j.seizure.2017.10.021] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/26/2017] [Accepted: 10/29/2017] [Indexed: 11/19/2022] Open
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Ding JM, Kanaan RAA. Conversion disorder: A systematic review of current terminology. Gen Hosp Psychiatry 2017; 45:51-55. [PMID: 28274339 DOI: 10.1016/j.genhosppsych.2016.12.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 12/20/2016] [Accepted: 12/21/2016] [Indexed: 10/20/2022]
Abstract
OBJECTIVE It has been argued that the label given to unexplained neurological symptoms is an important contributor to their often poor acceptance, and there has been recent debate on proposals to change the name from conversion disorder. There have been multiple studies of layperson and clinician preference and this article aimed to review these. DESIGN Multiple databases were searched using terms including "conversion disorder" and "terminology", and relative preferences for the terms extracted. RESULTS Seven articles were found which looked at clinician or layperson preferences for terminology for unexplained neurological symptoms. Most neurologists favoured terms such as "functional" and "psychogenic", while laypeople were comfortable with "functional" but viewed "psychogenic" as more offensive; "non-epileptic/organic" was relatively popular with both groups. CONCLUSIONS "Functional" is a term that is relatively popular with both clinicians and the public. It also meets more of the other criteria proposed for an acceptable label than other popular terms - however the views of neither psychiatrists nor actual patients with the disorder were considered.
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Affiliation(s)
- Juen Mei Ding
- University of Melbourne, Department of Psychiatry, Austin Health, Heidelberg, VIC 3084, Australia
| | - Richard Antony Alexander Kanaan
- University of Melbourne, Department of Psychiatry, Austin Health, Heidelberg, VIC 3084, Australia; King's College London, Department of Psychological Medicine, Institute of Psychiatry, Weston Education Centre, Denmark Hill, London SE5 9RJ, UK.
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What should we say to patients with unexplained neurological symptoms? How explanation affects offence. J Psychosom Res 2016; 91:55-60. [PMID: 27894463 DOI: 10.1016/j.jpsychores.2016.10.012] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Revised: 10/13/2016] [Accepted: 10/30/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVES Unexplained neurological symptoms (UNS) are common presentations in neurology but there is no consensus as to what they should be called. This is important, as patient acceptance is a predictor of outcome and there is evidence that patients are unhappy with the terms used. Patient understanding of these terms may be limited, however, and, once explained, the terms may seem more or less offensive. We sought to elicit patients' views of 7 frequently used terms for UNS, and whether these changed once definitions were provided. METHODS 185 participants were recruited from a medical outpatients' waiting area. They were given questionnaires outlining a hypothetical situation of leg weakness, with 7 possible labels. Participants were asked whether they endorsed 4 connotations for each label and the "number needed to offend" (NNO) calculated, before and after definitions were given. RESULTS It was found that "functional" was significantly less offensive than other terms used (NNO 17, compared with "Conversion Disorder" NNO 5, p<0.001). Reported understanding of the terms was generally low, however, and many terms became significantly more offensive once definitions were provided. Participants' reported understanding had a significant effect, with low understanding causing terms to be viewed as more offensive after explanation. CONCLUSION Much of the 'offence' in UNS lies not in the terminology but in the meaning those terms carry. This study replicated previous findings that "functional" was less offensive than other terms, even after explanation, but in common with most terms this was partly due to patients' limited understanding of its meaning.
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Takasaki K, Diaz Stransky A, Miller G. Psychogenic Nonepileptic Seizures: Diagnosis, Management, and Bioethics. Pediatr Neurol 2016; 62:3-8. [PMID: 27400821 DOI: 10.1016/j.pediatrneurol.2016.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Revised: 04/17/2016] [Accepted: 04/20/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The diagnosis and management of psychogenic nonepileptic seizures (PNES) is often challenging and fraught with discord and disagreement between patients, parents, and physicians. Furthermore, there are ethical challenges when making the diagnosis, communicating this information, and instituting management. METHODS We reviewed the current body of knowledge regarding the characteristic differences between epileptic seizures and PNES, and the high incidence of psychiatric comorbidities. An ethical analysis was made of diagnosis and management based on ethical principles, virtue ethics, and the social contract that health professionals have with patients. RESULTS Key distinctions between PNES and epilepsy lie in both patient and seizure characteristics. Long duration, eye closure, asynchronous movements, frequent recurrence in the same context, intra-ictal awareness, and lack of post ictal state are useful in helping establish the diagnosis. Psychiatric comorbidities, history of abuse, cognitive impairment, and multiple non specific somatic complaints are some salient patient features that should increase suspicion for the diagnosis of PNES. However, definitive diagnosis rests on capturing the events on video EEG. CONCLUSION Effective diagnosis and management of PNES requires the use of video EEG and an early collaborative approach between pediatricians, neurologists, psychiatrists, nursing staff, and other professional colleagues. Ethical questions that may arise should be addressed with the virtues of competence, courage, compassion, prudence, and honesty; and the principles of respect beneficence, and the avoidance of unnecessary harm.
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Affiliation(s)
- Kaoru Takasaki
- Yale University School of Medicine, New Haven, Connecticut
| | - Andrea Diaz Stransky
- Child Study Center, Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut
| | - Geoffrey Miller
- Department of Pediatrics, Program for Biomedical Ethics, Yale University School of Medicine, New Haven, Connecticut.
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McWilliams A, Reilly C, McFarlane FA, Booker E, Heyman I. Nonepileptic seizures in the pediatric population: A qualitative study of patient and family experiences. Epilepsy Behav 2016; 59:128-36. [PMID: 27131915 DOI: 10.1016/j.yebeh.2016.03.029] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2016] [Revised: 03/10/2016] [Accepted: 03/20/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVE The objective of this study was to characterize the experience of nonepileptic seizures (NES) in young people (0-19years) and their families, referred to a UK specialist (tertiary) pediatric hospital. The topics investigated include: accessing healthcare, how the diagnosis was first explained, impact on home life and school, coping strategies, and ideas about naming and causes. METHODS Ten young people with NES and 29 family members took part in focus groups and telephone interviews. The data generated were analyzed qualitatively with thematic analysis. RESULTS Six themes were identified from participant experiences: upset and afraid, missing out, feeling misunderstood, confusion and uncertainty, less than epilepsy, and making sense and moving on. Participants described severe disruption to multiple domains of functioning at home, educationally, and in social activities. Young people felt guilty but also overprotected, while family members felt that they were failing as parents. The journey to diagnosis and treatment was seen as unnecessarily tortuous, with access to care and treatment pathways poorly defined. Participants described feeling that a wide variety of professionals did not believe their experiences, showed pejorative attitudes, and left them feeling isolated and marginalized. The young people and family members found NES a difficult disorder to understand and sometimes could not differentiate it from epilepsy. Epilepsy was used as a benchmark for several comparisons, including highlighting the lack of support for and information about NES. Families disliked being told that it was "good news" that their child did not have epilepsy and questioned if their child should be present during initial diagnostic discussions. Participants described stressful situations as a common trigger for NES. Young people showed ambivalence towards the need to understand the condition or the choice of name used for it, whereas family members considered this crucial for achieving recovery. CONCLUSIONS Young people and families who live with NES experience considerable distress and impairment. Pathways to diagnosis need to be streamlined, and better integration of pediatric, mental health, and educational services is required. The use of the "good news" story to discuss the diagnosis with families should be reconsidered, as families seem to interpret this as indicating that there is no effective treatment. Educational resources and support groups for young people and families are needed. Greater understanding of experiences may allow investigation of the pathogenic mechanism and inform possible management approaches. Training of health professionals in communicating with young people and families with NES must be improved.
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Affiliation(s)
- Andrew McWilliams
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK; UCL Institute of Child Health, 30 Guildford St, University College London, London WC1N 1EH, UK; Barts and the London School of Medicine and Dentistry, Queen Mary University of London, Garrod Building, Turner St, London, E1 2AD, UK.
| | - Colin Reilly
- Research Department, Young Epilepsy, Lingfield, Surrey RH7 6PW, UK; Gillberg Neuropsychiatry Centre, University of Gothenburg, Kungsgatan 12, Gothenburg, Sweden
| | - Fiona A McFarlane
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK; UCL Institute of Child Health, 30 Guildford St, University College London, London WC1N 1EH, UK
| | - Emily Booker
- UCL Institute of Child Health, 30 Guildford St, University College London, London WC1N 1EH, UK
| | - Isobel Heyman
- Great Ormond Street Hospital for Children NHS Trust, Great Ormond Street, London WC1N 3JH, UK; UCL Institute of Child Health, 30 Guildford St, University College London, London WC1N 1EH, UK
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Psychogenic Paroxysmal Nonepileptic Events in Children: A Review. Pediatr Neurol 2015; 53:13-22. [PMID: 25987362 DOI: 10.1016/j.pediatrneurol.2015.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/28/2014] [Accepted: 03/17/2015] [Indexed: 11/22/2022]
Abstract
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.
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Whitehead K, Stone J, Norman P, Sharpe M, Reuber M. Differences in relatives' and patients' illness perceptions in functional neurological symptom disorders compared with neurological diseases. Epilepsy Behav 2015; 42:159-64. [PMID: 25516111 DOI: 10.1016/j.yebeh.2014.10.031] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Revised: 10/25/2014] [Accepted: 10/28/2014] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The illness perceptions of the relatives of patients with functional neurological symptom disorders (FNSDs) and their relation to the illness perceptions of the patients have been little studied. We aimed to compare illness perceptions of relatives of patients with FNSDs with those held by patients themselves. We used control pairs with neurological diseases (NDs) to examine the specificity of the findings to FNSDs. MATERIAL AND METHODS Patients with FNSDs (functional limb weakness and psychogenic nonepileptic seizures) and patients with NDs causing limb weakness and epilepsy, as well as their relatives, completed adapted versions of the Illness Perception Questionnaire - Revised (IPQ-R). RESULTS We included 112 pairs of patients with FNSDs and their relatives and 60 pairs of patients with NDs and their relatives. Relatives of patients with FNSDs were more likely to endorse psychological explanations and, in particular, stress as causal factors than patients with FNSDs (p<.001). Relatives of patients with FNSDs were also more pessimistic about the expected duration of the disorder and perceived a greater emotional impact compared with patients themselves (p<.001). However, the latter two differences between patients and relatives were also found in pairs of patients with NDs and their relatives. CONCLUSION The main difference in illness perceptions between relatives and patients that appeared specific to FNSDs was a tendency for relatives to see psychological factors as more relevant compared with patients. Some other differences were observed between pairs of patients with FNSDs and their relatives, but the same differences were also seen in pairs of patients with NDs and their relatives. These other differences were, therefore, not specific to FNSDs. Discussion about possibly relevant psychological factors with patients suffering from FNSDs may be helped by including relatives.
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Affiliation(s)
- Kimberley Whitehead
- Department of Clinical Neurophysiology, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.
| | - Jon Stone
- Dept Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Rd, Edinburgh, EH4 2XU, UK.
| | - Paul Norman
- Department of Psychology, University of Sheffield, Sheffield S10 2TP, UK.
| | - Michael Sharpe
- Department of Psychiatry, University of Oxford, Oxford OX3 7JX, UK.
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.
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Karterud HN, Risør MB, Haavet OR. The impact of conveying the diagnosis when using a biopsychosocial approach: A qualitative study among adolescents and young adults with NES (non-epileptic seizures). Seizure 2015; 24:107-13. [PMID: 25458100 DOI: 10.1016/j.seizure.2014.09.006] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2014] [Revised: 09/22/2014] [Accepted: 09/24/2014] [Indexed: 11/26/2022] Open
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Wichaidit BT, Østergaard JR, Rask CU. Diagnostic practice of psychogenic nonepileptic seizures (PNES) in the pediatric setting. Epilepsia 2014; 56:58-65. [DOI: 10.1111/epi.12881] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Bianca T. Wichaidit
- The Research Clinic for Functional Disorders and Psychosomatics; Aarhus University Hospital; Aarhus Denmark
| | - John R. Østergaard
- The Department of Pediatrics; Aarhus University Hospital; Aarhus Denmark
| | - Charlotte U. Rask
- The Research Clinic for Functional Disorders and Psychosomatics; Aarhus University Hospital; Aarhus Denmark
- Child and Adolescent Psychiatric Center; Aarhus University Hospital; Aarhus Denmark
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Cole CM, Falcone T, Caplan R, Timmons-Mitchell J, Jares K, Ford PJ. Ethical dilemmas in pediatric and adolescent psychogenic nonepileptic seizures. Epilepsy Behav 2014; 37:145-50. [PMID: 25022823 PMCID: PMC4170022 DOI: 10.1016/j.yebeh.2014.06.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2014] [Revised: 06/10/2014] [Accepted: 06/12/2014] [Indexed: 11/17/2022]
Abstract
To date, only a very narrow window of ethical dilemmas in psychogenic nonepileptic seizures (PNES) has been explored. Numerous distinct ethical dilemmas arise in diagnosing and treating pediatric and adolescent patients with PNESs. Important ethical values at stake include trust, transparency, confidentiality, professionalism, autonomy of all stakeholders, and justice. In order to further elucidate the ethical challenges in caring for this population, an ethical analysis of the special challenges faced in four specific domains is undertaken: (1) conducting and communicating a diagnosis of PNESs, (2) advising patients about full transparency and disclosure to community including patients' peers, (3) responding to requests to continue antiepileptic drugs, and (4) managing challenges arising from school policy and procedure. An analysis of these ethical issues is essential for the advancement of best care practices that promote the overall well-being of patients and their families.
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Affiliation(s)
- Cristie M Cole
- Department of Bioethics, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Tatiana Falcone
- Neurological Institute, Department of Psychology and Psychiatry, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Epilepsy Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - Rochelle Caplan
- Department of Psychiatry and Behavioral Services, David Geffen School of Medicine at UCLA, 150 UCLA Medical Plaza, Los Angeles, CA 90095, USA; Department of Child and Adolescent Psychiatry, Brain Research Institute, UCLA, Box 951761, Los Angeles, CA, USA.
| | - Jane Timmons-Mitchell
- Begun Center for Violence Prevention Research and Education, Jack, Joseph and Morton Mandel School of Applied Social Sciences, Case Western Reserve University, 11402 Bellflower Road, Cleveland, OH 44106, USA.
| | - Kristine Jares
- Department of Social Work, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Paul J Ford
- Department of Bioethics, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; Epilepsy Center, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA; NeuroEthics Program, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
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