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Kozlowska K, Scher S. Recent advances in understanding the neurobiology of pediatric functional neurological disorder. Expert Rev Neurother 2024; 24:497-516. [PMID: 38591353 DOI: 10.1080/14737175.2024.2333390] [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: 05/26/2023] [Accepted: 03/18/2024] [Indexed: 04/10/2024]
Abstract
INTRODUCTION Functional neurological disorder (FND) is a neuropsychiatric disorder that manifests in a broad array of functional motor, sensory, or cognitive symptoms, which arise from complex interactions between brain, mind, body, and context. Children with FND make up 10%-20% of presentations to neurology services in children's hospitals and up to 20% of adolescents admitted to hospital for the management of intractable seizures. AREAS COVERED The current review focuses on the neurobiology of pediatric FND. The authors present an overview of the small but growing body of research pertaining to the biological, emotion-processing, cognitive, mental health, physical health, and social system levels. EXPERT OPINION Emerging research suggests that pediatric FND is underpinned by aberrant changes within and between neuron-glial (brain) networks, with a variety of factors - on multiple system levels - contributing to brain network changes. In pediatric practice, adverse childhood experiences (ACEs) are commonly reported, and activation or dysregulation of stress-system components is a frequent finding. Our growing understanding of the neurobiology of pediatric FND has yielded important flow-on effects for assessing and diagnosing FND, for developing targeted treatment interventions, and for improving the treatment outcomes of children and adolescents with FND.
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Affiliation(s)
- Kasia Kozlowska
- The Children's Hospital at Westmead, Westmead, NSW, Australia
- Brain Dynamics Centre, Westmead Institute of Medical Research, Westmead, NSW, Australia
- University of Sydney Medical School, Camperdown, NSW, Australia
| | - Stephen Scher
- University of Sydney Medical School, Camperdown, NSW, Australia
- Department of Psychiatry, Harvard Medical School, Belmont, MA, USA
- McLean Hospital, Belmont, MA, USA
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Tanner AL, von Gaudecker JR, Crowder SJ, Buelow JM, Miller WR. Adolescents' qualitative expressions of functional seizure illness representation. J Adolesc 2024; 96:370-380. [PMID: 38053309 PMCID: PMC10872507 DOI: 10.1002/jad.12281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 11/22/2023] [Accepted: 11/24/2023] [Indexed: 12/07/2023]
Abstract
INTRODUCTION Adolescents with functional (nonepileptic) seizures experience challenges self-managing this mental health condition, especially at school where adolescents experience stress, bullying, accusations of faking seizures, and stigma. According to the Common Sense Model of Self-Regulation, adolescents' self-management decisions and outcomes may be shaped by their functional seizure illness representation (perceptions or mental depictions formed in response to a health threat). However, current research has only explored adults' functional seizure illness representation; little is known about adolescents. The aim of this study was to explore adolescents' expressions of illness representation characteristics (identity, cause, consequence, controllability/curability, and timeline) when describing their experience attending school with functional seizures. METHODS We analyzed qualitative data from 10 adolescents (age 12-19 years, 100% female) from the United States with functional seizures. Data collection occurred in 2019 via semistructured interviews about adolescents' school experiences. The theme of illness representation emerged without prompting adolescents to discuss illness representation or its characteristics. This study involved inductive analyses and magnitude coding of adolescents' unsolicited expressions of illness representation. RESULTS All five characteristics of illness representation were mentioned by adolescents; however, not all characteristics were mentioned by all adolescents. Adolescents' expressions of illness representation characteristics resulted in the following descriptive themes: clashing labels and mind-body façade for identity, stress for cause, gains and losses for consequence, control/lack of control for controllability/curability, and no end of seizures in sight for timeline. CONCLUSIONS Adolescents' expressions of illness representation reveal perceptions considered "threatening" within the Common Sense Model, especially those expressing lack of controllability/curability and condition timelines with no end in sight. The Common Sense Model offers a framework for understanding how these threatening perceptions may impact health and academic outcomes or change with intervention.
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Affiliation(s)
- Andrea L Tanner
- School of Nursing, Indiana University, Bloomington, Indiana, USA
| | | | | | - Janice M Buelow
- School of Nursing, Indiana University, Indianapolis, Indiana, USA
| | - Wendy R Miller
- School of Nursing, Indiana University, Indianapolis, Indiana, USA
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Charney M, Foster S, Shukla V, Zhao W, Jiang SH, Kozlowska K, Lin A. Neurometabolic alterations in children and adolescents with functional neurological disorder. Neuroimage Clin 2023; 41:103557. [PMID: 38219534 PMCID: PMC10825645 DOI: 10.1016/j.nicl.2023.103557] [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: 09/23/2023] [Revised: 11/22/2023] [Accepted: 12/18/2023] [Indexed: 01/16/2024]
Abstract
OBJECTIVES In vivo magnetic resonance spectroscopy (MRS) was used to investigate neurometabolic homeostasis in children with functional neurological disorder (FND) in three regions of interest: supplementary motor area (SMA), anterior default mode network (aDMN), and posterior default mode network (dDMN). Metabolites assessed included N-acetyl aspartate (NAA), a marker of neuron function; myo-inositol (mI), a glial-cell marker; choline (Cho), a membrane marker; glutamate plus glutamine (Glx), a marker of excitatory neurotransmission; γ-aminobutyric acid (GABA), a marker of inhibitor neurotransmission; and creatine (Cr), an energy marker. The relationship between excitatory (glutamate and glutamine) and inhibitory (GABA) neurotransmitter (E/I) balance was also examined. METHODS MRS data were acquired for 32 children with mixed FND (25 girls, 7 boys, aged 10.00 to 16.08 years) and 41 healthy controls of similar age using both short echo point-resolved spectroscopy (PRESS) and Mescher-Garwood point-resolved spectroscopy (MEGAPRESS) sequences in the three regions of interest. RESULTS In the SMA, children with FND had lower NAA/Cr, mI/Cr (trend level), and GABA/Cr ratios. In the aDMN, no group differences in metabolite ratios were found. In the pDMN, children with FND had lower NAA/Cr and mI/Cr (trend level) ratios. While no group differences in E/I balance were found (FND vs. controls), E/I balance in the aDMN was lower in children with functional seizures-a subgroup within the FND group. Pearson correlations found that increased arousal (indexed by higher heart rate) was associated with lower mI/Cr in the SMA and pDMN. CONCLUSIONS Our findings of multiple differences in neurometabolites in children with FND suggest dysfunction on multiple levels of the biological system: the neuron (lower NAA), the glial cell (lower mI), and inhibitory neurotransmission (lower GABA), as well as dysfunction in energy regulation in the subgroup with functional seizures.
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Affiliation(s)
- Molly Charney
- Department of Neurology, Columbia University Irving Medical Center, New York-Presbyterian, New York, NY, USA; Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sheryl Foster
- Sydney School of Health Sciences, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Radiology, Westmead Hospital, Westmead, NSW 2145, Australia
| | - Vishwa Shukla
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Wufan Zhao
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sam H Jiang
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW 2145, Australia; Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia; Brain Dynamics Centre, Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia.
| | - Alexander Lin
- Center for Clinical Spectroscopy, Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Winton-Brown T, Wilson SJ, Felmingham K, Rayner G, O'Brien TJ, O'Brien P, Mohan A, Velakoulis D, Kanaan R. Principles for delivering improved care of people with functional seizures: Closing the treatment gap. Aust N Z J Psychiatry 2023; 57:1511-1517. [PMID: 37394954 DOI: 10.1177/00048674231180509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/04/2023]
Abstract
Patients diagnosed with functional (psychogenic nonepileptic) seizures have similar or greater levels of disability, morbidity and mortality than people with epilepsy, but there are far fewer treatment services. In contrast to epilepsy, the current understanding of pathophysiological mechanisms and the development of evidence-based treatments for functional seizures is rudimentary. This leads to high direct healthcare costs and high indirect costs to the patient, family and wider society. There are many patient, clinician and system-level barriers to improving outcomes for functional seizures. At a patient level, these include the heterogeneity of symptoms, diagnostic uncertainty, family factors and difficulty in perceiving psychological aspects of illness and potential benefits of treatment. Clinician-level barriers include sub-specialism, poor knowledge, skills and attitudes and stigma. System-level barriers include the siloed nature of healthcare, the high prevalence of functional seizures and funding models relying on individual medical practitioners. Through the examination of international examples and expert recommendations, several themes emerge that may address some of these barriers. These include (1) stepped care with low-level, brief generalised interventions, proceeding to higher level, extended and individualised treatments; (2) active triage of complexity, acuity and treatment readiness; (3) integrated interdisciplinary teams that individualise formulation, triage, and treatment planning and (4) shared care with primary, emergency and community providers and secondary consultation. Consideration of the application of these principles to the Australian and New Zealand context is proposed as a significant opportunity to meet an urgent need.
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Affiliation(s)
- Toby Winton-Brown
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Alfred Mental and Addiction Health, Alfred Health, Melbourne, VIC, Australia
| | - Sarah J Wilson
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC, Australia
- Department of Clinical Neuropsychology and Department of Medicine, Austin Health, Heidelberg, VIC, Australia
| | - Kim Felmingham
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Genevieve Rayner
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, VIC, Australia
| | - Terence J O'Brien
- Department of Neuroscience, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Patrick O'Brien
- Department of Clinical Neurosciences, St Vincent's Hospital, Fitzroy, VIC, Australia
| | - Adith Mohan
- Centre for Healthy Brain Ageing, University of New South Wales, Randwick, NSW, Australia
- Neuropsychiatric Institute, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Dennis Velakoulis
- Neuropsychiatry, The Royal Melbourne Hospital, Melbourne, VIC, Australia
- Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
| | - Richard Kanaan
- Department of Psychiatry, The University of Melbourne, Melbourne, VIC, Australia
- Austin Health, Heidelberg, VIC, Australia
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Rao S, Burch M, Fredwall MM, Enciso L, Trott K, Patel AD, Albert DVF. Multidisciplinary Care for Pediatric Patients With Psychogenic Nonepileptic Seizures May Be Associated With Decreased Health Care Utilization. Neurol Clin Pract 2023; 13:1-6. [PMID: 37795502 PMCID: PMC10547481 DOI: 10.1212/cpj.0000000000200195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 08/28/2023] [Indexed: 10/06/2023]
Abstract
Background and Objectives Psychogenic nonepileptic seizures (PNES) are paroxysmal events that resemble epileptic seizures but have psychological underpinnings. Patients with PNES have high health care utilization. We hypothesize that appropriate care would lead to decreases in utilization. The aim of this study was to measure the impact of a multidisciplinary PNES clinic in reducing health care utilization (HCU) in youth with PNES referred to the clinic. Methods We reviewed the frequency of visits to the emergency department (ED), urgent care (UC), planned and unplanned hospitalizations, neurodiagnostic studies, and total charges associated with these encounters 12 months before and 12 months after initial referral to the clinic. Manual chart review of all patients referred from November 2017 to March 2020 was performed. Results Two hundred and twelve unique patients were included in this retrospective study. Patient sex was identified as 71% female, 28% male, and 1% other, with an average age of 14 years at diagnosis. These patients visited the ED a total of 410 times before being seen in the PNES clinic, which decreased to 187 visits after (75% reduction). All measures of HCU decreased in the 12 months after the visit, and statistically significant differences were observed in all measures of HCU except for head MRIs, leading to an estimated potential cost savings of $7,978,447. Discussion Patients with PNES were found to have decreased health care utilization in the 12 months after referral to the Nationwide Children's Hospital multidisciplinary clinic, including significant decreases in emergency services and unnecessary diagnostic testing, in the 12 months after the referral.
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Affiliation(s)
- Sahana Rao
- Ohio University Heritage College of Osteopathic Medicine (SR), Athens; Division of Neurology (MB, MMF, LE, ADP, DVFA), Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University; Division of Pediatrics and Neuropsychology (KT); and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Maggie Burch
- Ohio University Heritage College of Osteopathic Medicine (SR), Athens; Division of Neurology (MB, MMF, LE, ADP, DVFA), Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University; Division of Pediatrics and Neuropsychology (KT); and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Megan M Fredwall
- Ohio University Heritage College of Osteopathic Medicine (SR), Athens; Division of Neurology (MB, MMF, LE, ADP, DVFA), Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University; Division of Pediatrics and Neuropsychology (KT); and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Laurie Enciso
- Ohio University Heritage College of Osteopathic Medicine (SR), Athens; Division of Neurology (MB, MMF, LE, ADP, DVFA), Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University; Division of Pediatrics and Neuropsychology (KT); and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Kristen Trott
- Ohio University Heritage College of Osteopathic Medicine (SR), Athens; Division of Neurology (MB, MMF, LE, ADP, DVFA), Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University; Division of Pediatrics and Neuropsychology (KT); and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Anup D Patel
- Ohio University Heritage College of Osteopathic Medicine (SR), Athens; Division of Neurology (MB, MMF, LE, ADP, DVFA), Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University; Division of Pediatrics and Neuropsychology (KT); and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
| | - Dara V F Albert
- Ohio University Heritage College of Osteopathic Medicine (SR), Athens; Division of Neurology (MB, MMF, LE, ADP, DVFA), Department of Pediatrics, Nationwide Children's Hospital/The Ohio State University; Division of Pediatrics and Neuropsychology (KT); and The Center for Clinical Excellence (ADP), Nationwide Children's Hospital, Columbus, OH
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Kozlowska K, Schollar-Root O, Savage B, Hawkes C, Chudleigh C, Raghunandan J, Scher S, Helgeland H. Illness-Promoting Psychological Processes in Children and Adolescents with Functional Neurological Disorder. CHILDREN (BASEL, SWITZERLAND) 2023; 10:1724. [PMID: 38002815 PMCID: PMC10670544 DOI: 10.3390/children10111724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/03/2023] [Accepted: 10/06/2023] [Indexed: 11/26/2023]
Abstract
Previous studies suggest that subjective distress in children with functional neurological disorder (FND) is associated with stress-system dysregulation and modulates aberrant changes in neural networks. The current study documents illness-promoting psychological processes in 76 children with FND (60 girls and 16 boys, aged 10.00-17.08 years) admitted to the Mind-Body Program. The children completed a comprehensive family assessment and self-report measures, and they worked with the clinical team to identify psychological processes during their inpatient admission. A total of 47 healthy controls (35 girls and 12 boys, aged 8.58-17.92 years) also completed self-report measures, but were not assessed for illness-promoting psychological processes. Children with FND (vs. controls) reported higher levels of subjective distress (total DASS score, t(104.24) = 12.18; p ˂ 0.001) and more adverse childhood experiences across their lifespans (total ELSQ score, t(88.57) = 9.38; p ˂ 0.001). Illness-promoting psychological processes were identified in all children with FND. Most common were the following: chronic worries about schoolwork, friendships, or parental wellbeing (n = 64; 84.2%); attention to symptoms (n = 61; 80.3%); feeling sad (n = 58; 76.3%); experiencing a low sense of control (helplessness) in relation to symptoms (n = 44; 57.9%); pushing difficult thoughts out of mind (n = 44; 57.9%); self-critical rumination (n = 42; 55.3%); negative/catastrophic-symptom expectations (n = 40; 52.6%); avoidance of activities (n = 38; 50%); intrusive thoughts/feelings/memories associated with adverse events (n = 38, 50%); and pushing difficult feelings out of mind (n = 37; 48.7%). In children with FND-disabled enough to be admitted for inpatient treatment-illness-promoting psychological processes are part of the clinical presentation. They contribute to the child's ongoing sense of subjective distress, and if not addressed can maintain the illness process. A range of clinical interventions used to address illness-promoting psychological processes are discussed, along with illustrative vignettes.
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Affiliation(s)
- Kasia Kozlowska
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
- Child and Adolescent Heath and Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
- Brain Dynamics Centre, Westmead Institute of Medical Research, Faculty of Medicine and Health, University of Sydney, Westmead, NSW 2145, Australia
| | - Olivia Schollar-Root
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
| | - Blanche Savage
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
- Golden Wattle Clinical Psychology, 20 Jarrett St, Leichhardt, NSW 2040, Australia
| | - Clare Hawkes
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
| | - Catherine Chudleigh
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
- Golden Wattle Clinical Psychology, 20 Jarrett St, Leichhardt, NSW 2040, Australia
| | - Jyoti Raghunandan
- Department of Psychological Medicine, The Children’s Hospital at Westmead, Westmead, NSW 2145, Australia; (O.S.-R.); (B.S.); (C.H.); (J.R.)
| | - Stephen Scher
- Department of Psychiatry, McLean Hospital, Harvard Medical School, Boston, MA 02115, USA;
- Specialty of Psychiatry, Faculty of Medicine and Health, University of Sydney, Camperdown, NSW 2050, Australia
| | - Helene Helgeland
- Department of Child and Adolescent Mental Health in Hospitals, Oslo University Hospital, 0424 Oslo, Norway;
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Tanner AL, von Gaudecker JR, Buelow JM, Oruche UM, Miller WR. Adolescents' Perceptions of Functional Seizure Self-Management Strategies, Facilitators, and Barriers in the School Environment. J Psychosoc Nurs Ment Health Serv 2023; 61:19-27. [PMID: 37134281 PMCID: PMC10592598 DOI: 10.3928/02793695-20230424-04] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
Abstract
Adolescents with functional (psychogenic nonepileptic) seizures encounter many struggles within the school environment, including stress, bullying, stigmatization, and accusations of faking seizure events. Mental health nurses and school personnel are poised to support school-based self-management; unfortunately, to date, no evidence exists to detail effective school-based self-management strategies for adolescents with functional seizures. Therefore, in the current qualitative study, we examined adolescents' functional seizure self-management, perceived effectiveness, and facilitators and barriers using semi-structured interviews analyzed using content analysis. We interviewed 10 adolescent females aged 12 to 19 years. Themes of proactive (prior to seizure warning symptoms) and reactive (after seizure warning symptoms) self-management, involving protection, perseverance, and progress monitoring, emerged. Adolescents perceived proactive strategies as primarily effective, whereas reactive strategies were less effective. Adolescents identified school nurses and personnel, family, and peers as facilitators and barriers to self-management. Mental health nurses are positioned to provide care, co-create plans, and advocate for adolescents with functional seizures in collaboration with school nurses and personnel. [Journal of Psychosocial Nursing and Mental Health Services, 61(10), 19-27.].
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Vasquez A, Hilliker DR, Wirrell EC. Pediatric psychogenic non-epileptic seizures: A retrospective observational cohort study at a quaternary center. Epilepsy Behav 2023; 146:109359. [PMID: 37499579 DOI: 10.1016/j.yebeh.2023.109359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Abstract
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.
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Affiliation(s)
- Alejandra Vasquez
- Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Daniel R Hilliker
- Division of Child and Adolescent Psychology and Psychiatry, Mayo Clinic, Rochester, MN, United States
| | - Elaine C Wirrell
- Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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Garcia A. Pediatric Functional Neurologic Disorders. Pediatr Clin North Am 2023; 70:589-601. [PMID: 37121644 DOI: 10.1016/j.pcl.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023]
Abstract
Functional neurologic disorders are common in the pediatric population. Recently, there has been a renewed focus on functional neurologic disorders, leading to improvements in diagnosis and management. This review focuses on updates in clinical presentation, diagnosis, pathophysiology (including neuroimaging), and treatment of functional neurologic disorders in the pediatric population.
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Affiliation(s)
- Angela Garcia
- Department of Physical Medicine and Rehabilitation, University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue, Suite 1200, Pittsburgh, PA 15201, USA.
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Sawchuk T. Towards more targeted treatments in functional seizures. Epilepsy Behav 2023; 142:109183. [PMID: 36973150 DOI: 10.1016/j.yebeh.2023.109183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 03/14/2023] [Indexed: 03/29/2023]
Affiliation(s)
- Tyson Sawchuk
- Department of Pediatrics, Cumming School of Medicine; Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada.
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Kozlowska K, Chudleigh C, Savage B, Hawkes C, Scher S, Nunn KP. Evidence-Based Mind-Body Interventions for Children and Adolescents with Functional Neurological Disorder. Harv Rev Psychiatry 2023; 31:60-82. [PMID: 36884038 PMCID: PMC9997641 DOI: 10.1097/hrp.0000000000000358] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2023]
Abstract
LEARNING OBJECTIVES • Develop and implement treatment plans for children and adolescents with functional neurological disorder (FND)• Outline a plan to increase awareness and standardize the care for patients with FND using evidence-based interventions. ABSTRACT Functional neurological disorder (FND) in children and adolescents involves the biological embedding of lived experience in the body and brain. This embedding culminates in stress-system activation or dysregulation and in aberrant changes in neural network function. In pediatric neurology clinics, FND represents up to one-fifth of patients. Current research shows good outcomes with prompt diagnosis and treatment using a biopsychosocial, stepped-care approach. At present, however-and worldwide-FND services are scarce, the result of long-standing stigma and ingrained belief that patients with FND do not suffer from a real ("organic") disorder and that they therefore do not require, or even deserve, treatment. Since 1994, the Mind-Body Program for children and adolescents with FND at The Children's Hospital at Westmead in Sydney, Australia-run by a consultation-liaison team-has delivered inpatient care to hundreds of patients with FND and outpatient care to hundreds of others. For less-disabled patients, the program enables community-based clinicians to implement biopsychosocial interventions locally by providing a positive diagnosis (by a neurologist or pediatrician), a biopsychosocial assessment and formulation (by clinicians from the consultation-liaison team), a physical therapy assessment, and clinical support (from the consultation-liaison team and the physiotherapist). In this Perspective we describe the elements of a biopsychosocial mind-body program intervention capable of providing, as needed, effective treatment to children and adolescents with FND. Our aim is to communicate to clinicians and institutions around the world what is needed to establish effective community treatment programs, as well as hospital inpatient and outpatient interventions, in their own health care settings.
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Perjoc RS, Roza E, Vladacenco OA, Teleanu DM, Neacsu R, Teleanu RI. Functional Neurological Disorder-Old Problem New Perspective. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:1099. [PMID: 36673871 PMCID: PMC9859618 DOI: 10.3390/ijerph20021099] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 12/29/2022] [Accepted: 01/04/2023] [Indexed: 06/17/2023]
Abstract
Functional neurological disorder (FND) is a common issue in the pediatric population. The concept and our understanding of functional neurological disorders have changed over the past years, and new etiologic models and treatment plans have been explored. Knowledge about FND in the pediatric population, however, is lacking. The aim of this review is to provide an update on pediatric functional neurological disorder. We conducted a literature search of PubMed and SCOPUS databases and reviewed a total of 85 articles to gain insight into the current understanding of FND etiology, diagnosis, treatment, and prognosis in children and adolescents. Functional and high resolution MRI revealed abnormal connectivity and structural changes in patients with functional symptoms. The diagnostic criteria no longer require the presence of a psychological factor and instead focus on a rule-in diagnosis. Treatment of FND includes a clear communication of the diagnosis and the support of a multidisciplinary team. Although FND typically has a poor prognosis, better outcomes appear to have been achieved in children and young adults. We conclude that pediatric functional neurological disorder is a prevalent pathology and that this patient population has additional specific needs compared to the adult population.
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Affiliation(s)
- Radu-Stefan Perjoc
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
| | - Eugenia Roza
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
| | - Oana Aurelia Vladacenco
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
| | - Daniel Mihai Teleanu
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- Emergency University Hospital, 050098 Bucharest, Romania
| | - Roxana Neacsu
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
| | - Raluca Ioana Teleanu
- “Carol Davila” University of Medicine and Pharmacy, 020021 Bucharest, Romania
- “Dr. Victor Gomoiu” Children’s Hospital, 022102 Bucharest, Romania
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13
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Chung J, Mukerji S, Kozlowska K. Cortisol and α-amylase awakening response in children and adolescents with functional neurological (conversion) disorder. Aust N Z J Psychiatry 2023; 57:115-129. [PMID: 35297291 DOI: 10.1177/00048674221082520] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE Stress system dysregulation is considered to have an important role in the aetiology of paediatric functional neurological (conversion) disorder. This study examined salivary cortisol and α-amylase awakening responses in children with functional neurological disorder to determine activation patterns of the hypothalamic-pituitary-adrenal axis and sympathetic system. A healthy cortisol awakening response involves a robust increase in cortisol within 30 minutes of awakening. Alpha-amylase awakening response is variable in children. METHODS Cortisol and α-amylase were measured in saliva from 32 patients with functional neurological disorder (26 girls and 6 boys, aged 11.3-16.1 years) and 31 healthy controls (23 girls and 8 boys, aged 8.6-17.7 years). Saliva samples were collected using a Salivette sampling device at two time points - upon awakening and 30 minutes after awakening. RESULTS Patients with functional neurological disorder showed a decrease in cortisol awakening response (-4 nmol.min/L) and controls showed an increase (107 nmol.min/L), t(55) = -.4.6, p < 0.001. Within the functional neurological disorder group, 57% showed an attenuated cortisol awakening response and 43% showed an obliterated/reversed cortisol awakening response: Cortisol awakening response was negatively correlated with adverse childhood experiences, r(58) = -0.6, p = 0.002, and subjective distress (total Depression Anxiety and Stress Scales score), r(58) = -0.4, p = 0.050. In controls, cortisol awakening response showed no correlation with adverse childhood experiences and a positive correlation with subjective distress, r(56) = 0.4, p = 0.023. Total cortisol remained similar between the functional neurological disorder and control group. No significant differences were observed between the functional neurological disorder and control group in any of the α-amylase analyses. DISCUSSION The results suggest dysregulation of the hypothalamic-pituitary-adrenal axis in children with functional neurological disorder. Hypothalamic-pituitary-adrenal dysregulation in children with functional neurological disorder may contribute to comorbid symptoms of fatigue, sleep disturbance and subjective loss of well-being because circadian rhythms and energy metabolism are disrupted. Hypothalamic-pituitary-adrenal dysregulation - and changes in glucocorticoid (cortisol) signalling at the molecular level - may also contribute to increased vulnerability for functional neurological disorder symptoms because of epigenetically mediated changes to neural networks implicated in functional neurological disorder.
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Affiliation(s)
- Jason Chung
- Department of Clinical Biochemistry, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
| | - Shohini Mukerji
- Department of Clinical Biochemistry, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Department of Chemical Pathology, St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia
| | - Kasia Kozlowska
- Faculty of Medicine and Health, Sydney Medical School, The University of Sydney, Sydney, NSW, Australia.,Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia.,Brain Dynamics Centre, The Westmead Institute for Medical Research, Westmead, NSW, Australia
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14
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Yang T, Roberts C, Winton-Brown T, Lloyd M, Kwan P, O'Brien TJ, Velakoulis D, Rayner G, Malpas CB. Childhood trauma in patients with epileptic vs nonepileptic seizures. Epilepsia 2023; 64:184-195. [PMID: 36300720 PMCID: PMC10100454 DOI: 10.1111/epi.17449] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 10/24/2022] [Accepted: 10/25/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVE Childhood trauma has been implicated as a risk factor for the etiology of psychogenic nonepileptic seizures (PNES). Relatively little attention has been paid to whether profiles of specific trauma types differ between patients with epilepsy and PNES. Investigating childhood trauma profiles in these patient groups may identify psychological vulnerabilities that predispose to developing PNES, and aid early diagnoses, prevention, and treatment. METHODS Data were collected from two cohorts (nRetrospective = 203; nProspective = 209) admitted to video-electroencephalography (EEG) monitoring units in Melbourne Australia. The differences in Childhood Trauma Questionnaire domain score between patient groups were investigated using standardized effect sizes and general linear mixed-effects models (GLMMs). Receiver-operating characteristic curves were used to investigate classification accuracy. RESULTS In the retrospective cohort, patients diagnosed with PNES reported greater childhood emotional abuse, emotional neglect, physical abuse, sexual abuse, and physical neglect relative to patients with epilepsy. These differences were replicated in the prospective cohort, except for physical abuse. GLMMs revealed significant main effects for group in both cohorts, but no evidence for any group by domain interactions. Reported sexual abuse showed the best screening performance of PNES, although no psychometric scores were adequate as isolated measures. SIGNIFICANCE Patients with PNES report a greater frequency of childhood trauma than patients with epilepsy. This effect appears to hold across all trauma types, with no strong evidence emerging for a particular trauma type that is more prevalent in PNES. From a practical perspective, inquiry regarding a history of sexual abuse shows the most promise as a screening measure.
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Affiliation(s)
- Tianren Yang
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, Victoria, Australia
| | - Caitlin Roberts
- Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia
| | - Toby Winton-Brown
- Alfred Brain, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Psychiatry, Alfred Health, Melbourne, Victoria, Australia
| | - Michael Lloyd
- Alfred Brain, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Psychiatry, Alfred Health, Melbourne, Victoria, Australia
| | - Patrick Kwan
- Alfred Brain, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Terence J O'Brien
- Alfred Brain, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Dennis Velakoulis
- Neuropsychiatry, Royal Melbourne Hospital, Melbourne, Victoria, Australia.,Department of Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Genevieve Rayner
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Alfred Brain, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia.,Department of Medicine, Austin Hospital, The University of Melbourne, Melbourne, Victoria, Australia
| | - Charles B Malpas
- Melbourne School of Psychological Sciences, The University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, Victoria, Australia.,Alfred Brain, Alfred Health, Melbourne, Victoria, Australia.,Department of Neuroscience, Central Clinical School, Monash University, Melbourne, Victoria, Australia
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15
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Tanner AL, von Gaudecker JR, Buelow JM, Oruche UM, Miller WR. "It's hard!": Adolescents' experience attending school with psychogenic nonepileptic seizures. Epilepsy Behav 2022; 132:108724. [PMID: 35641373 PMCID: PMC9379857 DOI: 10.1016/j.yebeh.2022.108724] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/19/2022] [Accepted: 04/28/2022] [Indexed: 12/01/2022]
Abstract
Adolescents with psychogenic nonepileptic seizures (PNES) face many challenges in the school setting. Researchers have identified school stressors as potential predisposing, precipitating, and perpetuating factors for PNES. However, few researchers have explored the perspectives of adolescents with PNES regarding their experiences of attending school, where they spend much of their time. Therefore, this qualitative study employed content analysis to explore the experience of attending school as an adolescent with PNES. Ten adolescents (100% female, 80% White) were interviewed. With an overwhelming response of "It's hard!" from respondents, five themes regarding the school experience emerged: stress, bullying, accusations of "faking" seizure events, feeling left out because of the condition, and school-management of PNES. Underlying these themes were expressions of the need for increased understanding from and collaboration among peers, as well as the need for increased understanding from families, healthcare providers, and school personnel including school nurses. Study findings should inform future adolescent PNES research, practice decisions made by healthcare providers in the health and education sectors, education of healthcare and school professionals, and policy development and implementation.
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Affiliation(s)
- Andrea L Tanner
- Indiana University-Purdue University Indianapolis, School of Nursing, 600 Barnhill Drive, Indianapolis, IN 46202, United States.
| | - Jane R von Gaudecker
- Indiana University-Purdue University Indianapolis, School of Nursing, 600 Barnhill Drive, Indianapolis, IN 46202, United States.
| | - Janice M Buelow
- Indiana University-Purdue University Indianapolis, School of Nursing, 600 Barnhill Drive, Indianapolis, IN 46202, United States.
| | - Ukamaka M Oruche
- Indiana University-Purdue University Indianapolis, School of Nursing, 600 Barnhill Drive, Indianapolis, IN 46202, United States.
| | - Wendy R Miller
- Indiana University-Purdue University Indianapolis, School of Nursing, 600 Barnhill Drive, Indianapolis, IN 46202, United States.
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16
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Stager L, Morriss S, McKibben L, Grant M, Szaflarski JP, Fobian AD. Sense of control, selective attention and cognitive inhibition in pediatric functional seizures: A prospective case-control study. Seizure 2022; 98:79-86. [PMID: 35430472 PMCID: PMC9081274 DOI: 10.1016/j.seizure.2022.03.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 03/28/2022] [Accepted: 03/29/2022] [Indexed: 11/21/2022] Open
Abstract
PURPOSE To date, laboratory-based experimental behavioral methods have not been used to identify factors associated with pediatric functional seizures (FS), leaving a critical gap for effective treatment development. METHODS Children ages 13-18 with video-EEG-confirmed FS were matched to controls (MCs) based on income, sex, race, and age. A modified Stroop task which included a condition requiring participants to report the ink colors in which seizure symptom words were written (e.g., "shaking" in blue) measured selective attention and cognitive inhibition through response time. The magic and turbulence task assessed sense of control in three conditions (magic, lag, turbulence). Children with FS were asked to report premonitory symptoms predicting FS. RESULTS Participants included 26 children with FS and 26 MCs (Meanage=15.2, 74% female, 59% white). On Stroop, children with FS had a slower reaction time (Mean=1193.83) than MCs (Mean=949.26, p = 0.022) for seizure symptom words. Children with FS had significantly poorer sense of control in the turbulence condition of the magic and turbulence task (Mean=-3.99, SD=8.83) than MCs (Mean=-11.51, SD=7.87; t(20)=-2.61, p =0.017). Children with FS (Mean=-1.80, SD=6.54) also had significantly poorer sense of control in the magic condition than MCs (Mean=-5.57, SD=6.01; p =0.028). Ninety-eight percent of patients endorsed premonitory symptoms. CONCLUSION Compared with MCs, children with FS have (1) poorer selective attention and cognitive inhibition when presented with seizure-related information and (2) lower sense of control (i.e. poorer awareness that their control was manipulated). Premonitory symptoms were common. Sense of control, selective attention, and inhibition may be novel treatment targets for FS intervention.
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Affiliation(s)
- Lindsay Stager
- Department of Psychology, University of Alabama at Birmingham, United States
| | - Skylar Morriss
- Department of Psychology, University of Alabama at Birmingham, United States
| | - Lauren McKibben
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States; Department of Anesthesiology, University of North Carolina, Chapel Hill, United States
| | - Merida Grant
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States
| | - Jerzy P Szaflarski
- Departments of Neurology, Neurosurgery and Neurobiology and the UAB Epilepsy Center, University of Alabama at Birmingham, United States
| | - Aaron D Fobian
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham, United States.
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17
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Psychogenic Nonepileptic Seizures in Children and Adolescents. Semin Pediatr Neurol 2022; 41:100949. [PMID: 35450667 DOI: 10.1016/j.spen.2021.100949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 12/10/2021] [Accepted: 12/10/2021] [Indexed: 11/20/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) are a common condition seen in children and adolescents. The diagnosis is clinical, based on a description of events, and can be supported using video electroencephalography recording. Children and adolescents with PNES often have comorbid psychiatric conditions and psychosocial stressors, although this is not a requisite for diagnosis. The pathophysiology is not fully understood but may be related to emotional processing and underlying aberrant functional connectivity. Communication of the diagnosis to patients and families in a compassionate way that leads to understanding is of paramount importance and the key first step to treatment. Psychotherapy that utilizes principles of cognitive behavioral therapy is the current standard for therapy. Symptoms can improve and many with PNES do experience remission of events with treatment, although not all. There is still much to be elucidated regarding underlying mechanisms and best treatments to help patients with this condition. In this article I review current knowledge about PNES in children and adolescents as well as share practical advice gleaned from clinical experience at Nationwide Children's Hospital's PNES Clinic.
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18
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Elliott L, Carberry C. Treatment of Pediatric Functional Neurological Symptom Disorder: A Review of the State of the Literature. Semin Pediatr Neurol 2022; 41:100952. [PMID: 35450669 DOI: 10.1016/j.spen.2022.100952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Revised: 01/11/2022] [Accepted: 01/11/2022] [Indexed: 11/26/2022]
Abstract
Functional Neurological Symptom Disorder (FNSD), or experiencing neurological symptoms incompatible with either a neurological condition or a medical condition, is a common condition presenting in children and adolescents. It is associated with impairment in quality of life for patients and their families and represents a significant burden to the healthcare system. There is currently limited research available regarding effective treatment of pediatric FNSD. Currently, only one RCT exists studying effective treatment of FNSD in children and adolescents, and it is limited to one sub-type of FNSD and only examined cognitive behavioral therapy compared to supportive therapy. Despite this, almost all published research supports good prognosis for pediatric FNSD with all studies reporting improvement either in FNSD symptoms or in the quality of life and functioning of patients with FNSD. The most support was found for the use of cognitive behavioral therapy either as a stand-alone treatment or in the context of interdisciplinary treatment. Future research should focus on increasing the rigor of research, including expanding RCTs to include additional sub-types of FNSD and comparing across various treatment modalities.
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Affiliation(s)
- Lindsey Elliott
- Department of Psychiatry and Behavioral Sciences, Univeristy of Texas at Austin, Austin, TX.
| | - Caroline Carberry
- Department of Educational Psychology, University of Texas at Austin, Austin, TX
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19
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Stager L, Morriss S, Szaflarski JP, Fobian AD. Psychiatric and personality factors in pediatric functional seizures: A prospective case-control study. Seizure 2022; 98:105-112. [PMID: 35462300 PMCID: PMC9081249 DOI: 10.1016/j.seizure.2022.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2022] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022] Open
Abstract
PURPOSE This study assessed psychiatric and personality characteristics in relation to pediatric functional seizures (FS). METHODS In a 1:1 prospectively matched-control study design, children with documented FS (confirmed via video EEG; ages 13-18) were matched to controls (MCs) on income, sex, race, and age. Primary outcomes were Behavior Assessment System for Children, Second Edition (BASC-2) and Millon Adolescent Clinical Inventory (MACI). Secondary measures included questionnaires assessing trauma, somatization, body awareness and quality of life (QOL). T-tests investigated differences between groups on T-scores. Due to lack of significant outcomes, an experimental analysis was conducted assessing differences in number of clinically elevated BASC-2 and MACI scores between groups. Binary logistic regressions determined the influences of clinically elevated scores on likelihood participants have FS. T-tests assessed differences on secondary measures. RESULTS Participants included 84 children, 42 with FS and 42 MCs (Children with FS: Meanage=15.4, Interquartile Rangeage=3; 73.5% female; 59.5% white). Children with FS had greater parent-reported somatization (t(23)=5.67, p<0.001) on BASC-2, greater somatization on CSSI-24 (t(35)=6.83, p<0.001), and poorer QOL (t(41)=-6.22; p<0.001) than MCs. There were no differences in clinically elevated BASC-2 or MACI scores compared to MCs and clinically elevated scores did not influence likelihood participants have FS. CONCLUSIONS Children with FS had greater somatization and poorer QOL but similar rates of psychiatric symptoms, trauma, and maladaptive personality traits compared to MCs. Psychiatric or personality factors did not predict likelihood of FS. Explanations of pediatric FS should consider novel contributors to FS rather than relying solely on a psychiatric etiology.
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20
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Treatment Approaches for Functional Neurological Disorders in Children. Curr Treat Options Neurol 2022; 24:77-97. [PMID: 35370394 PMCID: PMC8958484 DOI: 10.1007/s11940-022-00708-5] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2021] [Indexed: 12/18/2022]
Abstract
Abstract
Purpose of Review
Functional neurological disorder (FND) is a multi-network brain disorder that encompasses a broad range of neurological symptoms. FND is common in pediatric practice. It places substantial strains on children, families, and health care systems. Treatment begins at assessment, which requires the following: the medical task of making the diagnosis, the interpersonal task of engaging the child and family so that they feel heard and respected, the communication task of communicating and explaining the diagnosis, and the logistical task of organizing treatment.
Recent Findings
Over the past decade, three treatment approaches—Retraining and Control Therapy (ReACT), other cognitive-behavioral therapies, and multidisciplinary rehabilitation—have been evaluated in the USA, Canada, and Australia. Of children treated in such programs, 63 − 95% showed full resolution of FND symptoms. The common thread across the programs is their biopsychosocial approach—consideration of biological, psychological, relational, and school-related factors that contribute to the child’s clinical presentation.
Summary
Current research strongly supports a biopsychosocial approach to pediatric FND and provides a foundation for a stepped approach to treatment. Stepped care is initially tailored to the needs of the individual child (and family) based on the pattern and severity of FND presentation. The level of care and type of intervention may then be adjusted to consider the child’s response, over time, to treatment or treatment combinations. Future research is needed to confirm effective treatment targets, to inform the development of stepped care, and to improve methodologies that can assess the efficacy of stepped-care interventions.
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21
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Joshi C. Furthering the Evidence of Comorbid Psychiatric Disorders in Pediatric Patients With Psychogenic Nonepileptic Seizures. Epilepsy Curr 2021; 22:114-116. [PMID: 35444502 PMCID: PMC8988731 DOI: 10.1177/15357597211054944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Charuta Joshi
- Children’s Hospital Colorado Department of Neurology, Aurora, USA
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22
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Velani H, Gledhill J. The effectiveness of psychological interventions for children and adolescents with non-epileptic seizures. Seizure 2021; 93:20-31. [PMID: 34656015 DOI: 10.1016/j.seizure.2021.09.006] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2021] [Revised: 09/10/2021] [Accepted: 09/12/2021] [Indexed: 10/20/2022] Open
Abstract
BACKGROUND This article systematically reviews the literature on the effectiveness of psychological interventions for non-epileptic seizures (NES) in children and adolescents. METHODS Embase, Medline and PsycINFO were searched to December 2020, for articles published in English, which used an objective measure to evaluate the outcome of a psychological intervention for NES. Further studies were identified from reference lists and experts in the field were contacted for unpublished studies. RESULTS Twelve studies met inclusion criteria. Of these, four were set up with the primary aim of evaluating an intervention of which two used a control group, two were prospective outcome studies and eight looked at retrospective clinical data. Two studies evaluated a single treatment modality, the others multiple treatment components. Overall, psychoeducation, and top-down psychotherapy, such as cognitive therapies, were the most frequent interventions, with recent studies describing body-oriented (bottom-up) approaches. Analysis across all studies identified a range of additional intervention components which included assessment and/or treatment for co-morbidities, liaison with school and support for parents, highlighting the importance of individualised treatment packages. CONCLUSIONS There is a paucity of studies specifically evaluating interventions for NES. Though a range of approaches have been described in managing this patient group, with generally positive outcomes, it is not possible to conclude from the available literature that one treatment approach is superior to another, though the information may be helpful in developing management guidelines.
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Affiliation(s)
- Hemma Velani
- Locum consultant child and adolescent psychiatrist, Harrow CAMHS, CNWL, 322 Northolt Rd, South Harrow, Harrow HA2 8EQ, United Kingdom.
| | - Julia Gledhill
- Division of Psychiatry, Imperial College London, 2nd Floor Commonwealth Building, Du Cane Road, London W12 0NN, United Kingdom.
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23
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Kozlowska K, Sawchuk T, Waugh JL, Helgeland H, Baker J, Scher S, Fobian AD. Changing the culture of care for children and adolescents with functional neurological disorder. Epilepsy Behav Rep 2021; 16:100486. [PMID: 34761194 PMCID: PMC8567196 DOI: 10.1016/j.ebr.2021.100486] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 08/31/2021] [Accepted: 09/15/2021] [Indexed: 01/08/2023] Open
Abstract
As members of a multidisciplinary team of professionals who treat children and adolescents with functional neurological (conversion) disorder (FND), we highlight the pressing need to develop an FND-informed culture of care that takes into account recent advances in our understanding of this group of patients. Stories of clinical encounters in health care settings from around the world-told by children and adolescents with FND, their parents, and health professionals-portray an outdated culture of care characterized by iatrogenic stigma, erosion of empathy and compassion within the clinician-patient relationship, and a lack of understanding of FND and its complex neurobiology. After a brief exploration of the outdated culture, we share our counterstories: how we and our colleagues have worked, and continue to work, to create an FND-informed culture in the health systems where we practice. We discuss the therapeutic use of child-friendly language. We also discuss a range of structural, educational, and process interventions that can be used to promote FND-informed beliefs and attitudes, FND-informed clinician-patient encounters, and FND-informed referral processes, treatment pathways, and therapeutic interventions.
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Affiliation(s)
- Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Westmead, NSW, Australia
- University of Sydney Medical School, Sydney, NSW, Australia
- Westmead Institute for Medical Research, Westmead, NSW, Australia
| | - Tyson Sawchuk
- University of Calgary, Cumming School of Medicine, Department of Pediatrics, AB, Canada
- Alberta Children's Hospital Research Institute, Calgary, AB, Canada
- Alberta Children's Hospital, Calgary, AB, Canada
| | - Jeff L Waugh
- Division of Child Neurology, Department of Pediatrics, University of Texas Southwestern, Dallas, TX, USA
- Division of Neurology and Neurotherapeutics, University of Texas Southwestern, Dallas, TX, USA
| | - Helene Helgeland
- Department of Child and Adolescent Mental Health in Hospitals, Oslo University Hospital, Oslo, Norway
| | - Janet Baker
- Speech Pathology, Flinders University, Adelaide, SA, Australia
- University of Technology Sydney, Sydney, NSW, Australia
| | - Stephen Scher
- University of Sydney Medical School, Sydney, NSW, Australia
- Department of Psychiatry, Harvard Medical School and McLean Hospital, Belmont, MA, USA
| | - Aaron D Fobian
- Department of Psychiatry and Behavioral Neurobiology, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
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24
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Myers L, Sarudiansky M, Korman G, Baslet G. Using evidence-based psychotherapy to tailor treatment for patients with functional neurological disorders. Epilepsy Behav Rep 2021; 16:100478. [PMID: 34693243 PMCID: PMC8515382 DOI: 10.1016/j.ebr.2021.100478] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/22/2021] [Accepted: 08/24/2021] [Indexed: 01/08/2023] Open
Abstract
Functional neurological disorder (FND) frequently presents with comorbid psychopathology (e.g., anxiety, depressive, post-traumatic stress disorders (PTSD), somatic symptom and pain syndromes, and dissociative and personality disorders). It can become chronic and lead to unemployment and disability for many patients. Psychosocial factors play an important role in the onset and perpetuation of symptoms. Consequently, psychotherapy is recommended for the treatment of FND in general, and especially for the single symptom-based subtype of functional seizures (FS). Some of the psychotherapy approaches that have been utilized for FND include cognitive-behavioral therapy (CBT), third wave approaches, and psychodynamic psychotherapies as well as group therapeutic and psychoeducational interventions. For patients with FS and PTSD, prolonged exposure therapy, a CBT-based treatment has been implemented. The purpose of this manuscript is to describe and analyze specific elements (e.g., theoretical foundations, tools, targets, definitions of success) of the main psychotherapeutic approaches used in patients with FND. Our premise is that these modalities will overlap considerably in some respects. We will conclude by discussing how discrete differences may render them more suitable for subgroups of patients with FND or for patients at different timepoints of their recovery process.
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Affiliation(s)
- Lorna Myers
- Northeast Regional Epilepsy Group, United States
| | - Mercedes Sarudiansky
- National Council for Scientific and Technical Research (CONICET), Institute of Research in Psychology, Faculty of Psychology, University of Buenos Aires, Argentina
| | - Guido Korman
- National Council for Scientific and Technical Research (CONICET), Institute of Research in Psychology, Faculty of Psychology, University of Buenos Aires, Argentina
| | - Gaston Baslet
- Brigham and Women’s Hospital, Harvard Medical School, Boston, USA
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Fredwall M, Terry D, Enciso L, Burch MM, Trott K, Albert DVF. Outcomes of children and adolescents 1 year after being seen in a multidisciplinary psychogenic nonepileptic seizures clinic. Epilepsia 2021; 62:2528-2538. [PMID: 34339046 DOI: 10.1111/epi.17031] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Psychogenic nonepileptic seizures (PNES) are paroxysmal events that may involve altered subjective experience and change in motor activity with a psychological cause. The aim of this work is to describe a population of pediatric patients with PNES and identify factors predictive of 12-month outcomes. METHODS We conducted a prospective observational study of children and adolescents referred to the multidisciplinary Nationwide Children's Hospital PNES clinic between November 2017 and July 2019. Information was collected from patients during clinic visits and semistructured follow-up phone calls. Descriptive statistics and Fisher exact test were used for analysis. RESULTS Of the 139 consecutive patients referred to the PNES clinic, 104 were seen in clinic and 63 answered 12-month follow-up calls. Patients with comorbid epilepsy had increased rates of participation at 12-month follow-up (p = .04). Complete remission was achieved by 32% (20/63) of patients at 12 months. Combined PNES remission and improvement was 89% (56/63) at 12 months. Patients and families who were linked with counseling at 1 month were more likely to achieve remission at 12 months (p = .005). Less than half (44%, 28/63) of patients reached at 12 months had their events documented on video-electroencephalogram (EEG) at diagnosis; however, those who did were not more likely to be accepting of the diagnosis at 12 months (p = 1.0), be linked with counseling at 12 months (p = .59), or be event-free at 12 months (p = .79). SIGNIFICANCE Remission occurred in one third of patients by 12 months; however, improvement in events was seen in 89%. Connection to counseling by 1 month was associated with increased remission rates at 12 months. Capturing events on video-EEG was not associated with increased acceptance or event freedom at 12 months. Diagnosis should be followed by strong encouragement to connect with counseling quickly to achieve a goal of increasing 12-month PNES remission rates.
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Affiliation(s)
- Megan Fredwall
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Debbie Terry
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Laurie Enciso
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Maggie Mary Burch
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Kristen Trott
- Department of Pediatrics, Division of Psychology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Dara V F Albert
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
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Agarwal R, Gathers-Hutchins L, Stephanou H. Psychogenic non-epileptic seizures in children. Curr Probl Pediatr Adolesc Health Care 2021; 51:101036. [PMID: 34373198 DOI: 10.1016/j.cppeds.2021.101036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Psychogenic Non-Epileptic Seizures (PNES) are a relatively common condition in children. While their clinical presentation resembles epileptic seizures, the underlying cause for PNES involves a multitude of bio-psychosocial factors. Patients may be misdiagnosed with epilepsy and subjected to unnecessary treatments, often delaying the diagnosis for years. A strong understanding of its symptomatology is essential for diagnosis of PNES. Successful management depends on effective teamwork that involves the neurologist as well as mental health professionals. This paper reviews the various aspects of PNES in children with emphasis on the clinical presentation, diagnosis as well as the underlying psychological basis and treatment.
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Affiliation(s)
- Rajkumar Agarwal
- Division of Neurology, Dayton Children's Hospital, Dayton, Ohio, USA; Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA.
| | - Latisha Gathers-Hutchins
- Wright State University Boonshoft School of Medicine, Dayton, Ohio, USA; Division of Psychology, Dayton Children's Hospital, Dayton, Ohio, USA
| | - Hara Stephanou
- Department of School Psychology, Doctoral Student, St. John's University, New York City, New York, USA
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Hansen AS, Rask CU, Christensen AE, Rodrigo-Domingo M, Christensen J, Nielsen RE. Psychiatric Disorders in Children and Adolescents With Psychogenic Nonepileptic Seizures. Neurology 2021; 97:e464-e475. [PMID: 34031196 DOI: 10.1212/wnl.0000000000012270] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/23/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Knowledge regarding psychiatric disorders in children and adolescents with psychogenic nonepileptic seizures (PNES) is limited. This study outlines the spectrum and risk of psychiatric disorders in childhood-onset PNES. METHODS We performed a nationwide matched cohort study of children and adolescents with PNES 5 to 17 years of age at the time of diagnosis between January 1, 1996, and December 31, 2014. Two matched comparison groups were included: children and adolescents with epilepsy (ES) and children and adolescents without PNES or epilepsy, called healthy controls (HC). Outcomes were prevalent psychiatric disorders before index (i.e., date of diagnosis or corresponding date for HC) and incident psychiatric disorders 2 years after index. Relative risks (RRs) were calculated and adjusted for potential confounders. RESULTS We included 384 children and adolescents with validated PNES, 1,152 with ES, and 1,920 HC. Among the cases of PNES, 153 (39.8%) had prevalent psychiatric disorders and 150 (39.1%) had incident psychiatric disorders. Compared to the ES and HC groups, children and adolescents with PNES had elevated risks of both prevalent psychiatric disorders (adjusted RRPNES/ES 1.87, 95% confidence interval [CI] 1.59-2.21, adjusted RRPNES/HC 5.54, 95% CI 4.50-6.81) and incident psychiatric disorders (adjusted RRPNES/ES 2.33, 95% CI 1.92-2.83, adjusted RRPNES/HC 8.37, 95% CI 6.31-11.11). A wide spectrum of specific psychiatric disorders displayed elevated RRs. CONCLUSIONS Children and adolescents with PNES are at higher risk of a wide range of psychiatric disorders compared to children and adolescents with ES and HC. A careful psychiatric evaluation is warranted to optimize and individualize treatment.
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Affiliation(s)
- Anne Sofie Hansen
- From Psychiatry (A.S.H., A.-E.C., M.R.-D., R.E.N.), Aalborg University Hospital; Department of Clinical Medicine (A.S.H., R.E.N.), Aalborg University; Department of Child and Adolescent Psychiatry (C.U.R.), Research Unit, and Department of Neurology (J.C.), Aarhus University Hospital; and Department of Clinical Medicine (C.U.R., J.C.), Aarhus University, Denmark.
| | - Charlotte Ulrikka Rask
- From Psychiatry (A.S.H., A.-E.C., M.R.-D., R.E.N.), Aalborg University Hospital; Department of Clinical Medicine (A.S.H., R.E.N.), Aalborg University; Department of Child and Adolescent Psychiatry (C.U.R.), Research Unit, and Department of Neurology (J.C.), Aarhus University Hospital; and Department of Clinical Medicine (C.U.R., J.C.), Aarhus University, Denmark
| | - Ann-Eva Christensen
- From Psychiatry (A.S.H., A.-E.C., M.R.-D., R.E.N.), Aalborg University Hospital; Department of Clinical Medicine (A.S.H., R.E.N.), Aalborg University; Department of Child and Adolescent Psychiatry (C.U.R.), Research Unit, and Department of Neurology (J.C.), Aarhus University Hospital; and Department of Clinical Medicine (C.U.R., J.C.), Aarhus University, Denmark
| | - Maria Rodrigo-Domingo
- From Psychiatry (A.S.H., A.-E.C., M.R.-D., R.E.N.), Aalborg University Hospital; Department of Clinical Medicine (A.S.H., R.E.N.), Aalborg University; Department of Child and Adolescent Psychiatry (C.U.R.), Research Unit, and Department of Neurology (J.C.), Aarhus University Hospital; and Department of Clinical Medicine (C.U.R., J.C.), Aarhus University, Denmark
| | - Jakob Christensen
- From Psychiatry (A.S.H., A.-E.C., M.R.-D., R.E.N.), Aalborg University Hospital; Department of Clinical Medicine (A.S.H., R.E.N.), Aalborg University; Department of Child and Adolescent Psychiatry (C.U.R.), Research Unit, and Department of Neurology (J.C.), Aarhus University Hospital; and Department of Clinical Medicine (C.U.R., J.C.), Aarhus University, Denmark
| | - René Ernst Nielsen
- From Psychiatry (A.S.H., A.-E.C., M.R.-D., R.E.N.), Aalborg University Hospital; Department of Clinical Medicine (A.S.H., R.E.N.), Aalborg University; Department of Child and Adolescent Psychiatry (C.U.R.), Research Unit, and Department of Neurology (J.C.), Aarhus University Hospital; and Department of Clinical Medicine (C.U.R., J.C.), Aarhus University, Denmark
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Asadi-Pooya AA, Brigo F, Kozlowska K, Perez DL, Pretorius C, Sawchuk T, Saxena A, Tolchin B, Valente KD. Social aspects of life in patients with functional seizures: Closing the gap in the biopsychosocial formulation. Epilepsy Behav 2021; 117:107903. [PMID: 33740497 DOI: 10.1016/j.yebeh.2021.107903] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 02/23/2021] [Accepted: 02/23/2021] [Indexed: 01/20/2023]
Abstract
The human, as a biological system, is an open system embedded within larger systems -including the family, culture, and socio-political environment. In this context, a patient with functional seizures (FS) is embedded in relationships, educational/professional institutions, culture, and society. Both connection to these broader systems and the quality of these connections, as well as the soundness of each system in and of itself, influence the health and well-being of patients in positive or negative ways. The social aspects of life are important determinants of health and quality of life across the lifespan. The current narrative review brings out several overarching themes in patients with FS. Sections on attachment, marriage, social networking, and stigma highlight the central roles of supportive and affirmative relationships across the lifespan. The section on education underscores the importance of keeping children and youth with FS connected within their school environments, as well as managing any barriers - learning difficulties, school response to FS events, stigma, etc.-that can diminish this connection. Finally, the sections on employment and driving highlight the value of being an active participant in one's society. In summary, FS impacts patients across most social aspects of life domains regardless of age - factors that are important when developing biopsychosocial formulations. This review concludes that the multidisciplinary management of FS requires careful assessment of social aspects of life in patients which can then be targeted for treatment, to improve their quality of life, facilitating recovery, and reducing the risk of relapse.
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Affiliation(s)
- Ali A Asadi-Pooya
- Epilepsy Research Center, Shiraz University of Medical Sciences, Shiraz, Iran; Jefferson Comprehensive Epilepsy Center, Department of Neurology, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Francesco Brigo
- Department of Neurology, Hospital of Merano (SABES-ASDAA), Merano-Meran, Italy
| | - Kasia Kozlowska
- The Children's Hospital at Westmead, Westmead Institute of Medical Research, University of Sydney Medical School, Sydney, NSW, Australia.
| | - David L Perez
- Functional Neurological Disorder Clinical and Research Programs, Departments of Neurology and Psychiatry, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Chrisma Pretorius
- Department of Psychology, Stellenbosch University, Stellenbosch, South Africa.
| | - Tyson Sawchuk
- Department of Pediatrics, Cumming School of Medicine, Alberta, Canada; Alberta Children's Hospital Research Institute, University of Calgary, Alberta, Canada.
| | - Aneeta Saxena
- Epilepsy Division, Department of Neurology, Boston Medical Center, Boston University School of Medicine, Boston, MA, USA; Functional Neurological Disorder Clinical and Research Program, Department of Neurology, Massachusetts General Hospital, Boston, MA, USA.
| | - Benjamin Tolchin
- Yale Comprehensive Epilepsy Center, Department of Neurology, Yale School of Medicine, New Haven, CT, USA.
| | - Kette D Valente
- Laboratory of Clinical Neurophysiology, Department of Psychiatry, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, Brazil.
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Psychogenic Nonepileptic Seizures in Children and Adolescents. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Psychogenic non-epileptic seizures in children - psychophysiology & dissociative characteristics. Psychiatry Res 2020; 294:113544. [PMID: 33161178 DOI: 10.1016/j.psychres.2020.113544] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Accepted: 10/24/2020] [Indexed: 11/21/2022]
Abstract
The purpose of this study was to determine psychophysiology and dissociative characteristics of psychogenic non-epileptic seizures (PNES) in a clinical pediatric setting. A retrospective chart review was conducted over a 5-year period that included children meeting criteria for probable, clinically established or documented PNES. Of these, 33 patients (81%) underwent psychophysiology assessment as part of standardized care and were selected for study inclusion. Ages ranged from 10 to 17 years inclusive (70% female). The majority of patients were found to have some form of autonomic decompensation at baseline (82%) and lack of autonomic recovery from a cognitive stressor (58%). Inhibition of electrodermal skin response to laboratory stressor was associated with significantly longer duration of PNES illness (t=2.65, p=.013), while elevated heart rate (above 90th percentile) was associated with significantly higher frequency of PNES events in the month preceding diagnosis (t=3.1, p=.004). High levels of dissociation and hyperventilation symptoms were self-reported by adolescent patients (n=19) with a moderate degree of positive association (r=0.35, p=.038). The majority of patients (n= 25, 89%) were taught to correct respiratory CO2 levels during a single biofeedback training session. Conclusions: Child PNES populations appear to be characterized by chronic autonomic hyperarousal reflecting severity of their symptoms, which can feasibly be targeted for behavioral treatment.
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Psychogenic Non-Epileptic Status as Refractory, Generalized Hypertonic Posturing: Report of Two Adolescents. MEDICINA-LITHUANIA 2020; 56:medicina56100508. [PMID: 32998279 PMCID: PMC7600080 DOI: 10.3390/medicina56100508] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 09/25/2020] [Accepted: 09/28/2020] [Indexed: 11/16/2022]
Abstract
Psychogenic non-epileptic seizures (PNES) or dissociative seizures are found under the umbrella headings of functional/dissociative neurological disorders (FND) in psychiatric classifications (DSM-5; ICD-11). PNES are not characterized by any specific ictal or postictal EEG abnormalities. Patients with PNES can present with motor or non-motor symptoms, frequently associated with a change in the level of consciousness. PNES duration is variable, often longer than that of epileptic seizures. Prolonged PNES, sometimes termed PNES status, involve continuous or repetitive events that exceed 30 min. Prolonged PNES are often misdiagnosed as an epileptic event and are often inappropriately treated with high doses of antiseizure drugs. In this report, we describe two adolescent patients who presented with prolonged PNES characterized by generalized hypertonic posturing and low levels of consciousness. Despite multiple presentation to the Emergency department, and multiple normal video-EEG, the patients were misdiagnosed with epilepsy and were inappropriately treated with antiseizure medications. Both patients presented psychiatric comorbidity, consisting of a major depressive disorder, obsessive-compulsive symptoms, social withdrawal, difficulty of social interaction, and anxious-perfectionist personality traits. The episodes of prolonged PNES gradually declined within 18 months in both patients.
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Radmanesh M, Jalili M, Kozlowska K. Activation of Functional Brain Networks in Children With Psychogenic Non-epileptic Seizures. Front Hum Neurosci 2020; 14:339. [PMID: 33192376 PMCID: PMC7477327 DOI: 10.3389/fnhum.2020.00339] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/03/2020] [Indexed: 02/03/2023] Open
Abstract
Objectives Psychogenic non-epileptic seizures (PNES) have been hypothesized to emerge in the context of neural networks instability. To explore this hypothesis in children, we applied a graph theory approach to examine connectivity in neural networks in the resting-state EEG in 35 children with PNES, 31 children with other functional neurological symptoms (but no PNES), and 75 healthy controls. Methods The networks were extracted from Laplacian-transformed time series by a coherence connectivity estimation method. Results Children with PNES (vs. controls) showed widespread changes in network metrics: increased global efficiency (gamma and beta bands), increased local efficiency (gamma band), and increased modularity (gamma and alpha bands). Compared to controls, they also had higher levels of autonomic arousal (e.g., lower heart variability); more anxiety, depression, and stress on the Depression Anxiety and Stress Scales; and more adverse childhood experiences on the Early Life Stress Questionnaire. Increases in network metrics correlated with arousal. Children with other functional neurological symptoms (but no PNES) showed scattered and less pronounced changes in network metrics. Conclusion The results indicate that children with PNES present with increased activation of neural networks coupled with increased physiological arousal. While this shift in functional organization may confer a short-term adaptive advantage-one that facilitates neural communication and the child's capacity to respond self-protectively in the face of stressful life events-it may also have a significant biological cost. It may predispose the child's neural networks to periods of instability-presenting clinically as PNES-when the neural networks are faced with perturbations in energy flow or with additional demands.
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Affiliation(s)
| | - Mahdi Jalili
- School of Engineering, RMIT University, Melbourne, VIC, Australia
| | - Kasia Kozlowska
- Department of Psychological Medicine, The Children's Hospital at Westmead, Sydney, NSW, Australia.,The University of Sydney School of Medicine, Sydney, NSW, Australia.,Westmead Institute for Medical Research, Sydney, NSW, Australia
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