Psychogenic non-epileptic seizures: management and prognosis

The effects of racial and socioeconomic disparities on time to diagnosis and treatment of pediatric functional seizures in the United States

PURPOSE

The present study sought to assess the effects of racial and socioeconomic status in the United States on time to treatment and diagnosis of pediatric functional seizures (FS).

METHODS

Eighty adolescents and their parent/guardian completed a demographics questionnaire and reported date of FS onset, diagnosis, and treatment. Paired samples t-tests compared time between FS onset and diagnosis, onset and treatment, and diagnosis and treatment based on race (White vs racial minority), annual household income (≤$79,999 vs ≥$80,000), maternal and paternal education (≤Associate's Degree vs Bachelor's Degree), and combined parental education (≤Post-graduate training vs Graduate degree).

RESULTS

Adolescents with lower annual household income began treatment >6 months later than adolescents with greater annual household income (p = 0.049). Adolescents with lower maternal and paternal education (≤Associate's Degree vs Bachelor's Degree) began treatment >4 and ∼8.5 months later than adolescents with greater maternal and paternal education (p = 0.04; p = 0.03), respectively. Adolescents with lower maternal education also received a diagnosis >5 months later (p = 0.03). Adolescents without a mother or father with a graduate degree received a diagnosis and began treatment∼3 and >11 months later (p = 0.03; p = 0.01) than adolescents whose mother or father received a graduate degree, respectively. No racial differences were found.

CONCLUSIONS

Adolescents with lower annual household income and/or parental education experienced increased duration between FS onset and treatment and diagnosis. Research is needed to clarify the mechanisms underlying this relationship, and action is needed to reduce these disparities given FS duration is associated with poorer prognosis and greater effects on the brain.

Clinical characteristics of patients with refractory non-epileptic seizures

OBJECTIVES

This incidence of non-epileptic seizures (NES) is estimated at 1-35 per 100,000 population. While many patients achieve remission, a significant fraction of patients have a poor prognosis despite optimal interventions. This study reports on the characteristics of patients with refractory NES diagnosed and treated at a comprehensive epilepsy centre.

METHODS

A retrospective review of admissions to the Epilepsy Monitoring Unit identified patients diagnosed with NES over a 6-year period. Patients with refractory NES were identified through review of medical files. A diagnosis of refractory NES was assigned when patients experienced ongoing NES at least 1 year after diagnostic video-EEG monitoring. Data pertaining to predisposing, precipitating and perpetuating factors was collected on all patients and a comparative analysis was conducted between refractory and non-refractory cases.

RESULTS

66 patients with NES were identified, 35% were deemed refractory. There was no significant difference amongst predisposing factors between the groups. Psychosocial adversity and a clear precipitant proximate to the onset of NES were significantly more common in the refractory cohort. Unemployment at time of diagnosis was a significant perpetuating factor associated with poor outcome.

CONCLUSION

This study provides insight into the features associated with refractory NES and may serve to improve prognostication and management in this disabling condition.

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

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

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

BACKGROUND

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSION

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

Treatment Provided in Children and Adolescents with Functional Seizures-A Danish Nationwide Cohort

BACKGROUND

Functional seizures (FS) are episodes of paroxysmal involuntary movements and altered consciousness without the typical changes in the electroencephalography as with epilepsy. A multidisciplinary approach is the golden standard in the treatment of FS. This study examined the cross-sectoral collaboration and treatment modalities provided to children and adolescents after a diagnosis of FS.

METHOD

A Danish nationwide cohort, consisting of 334 children and adolescents, aged 5-17 years, with a validated diagnosis of FS during the period 2004-2014 was studied. Medical record data were collected from diagnosing hospital departments. Management and treatment modalities from the time of diagnosis up to three months after diagnosis were explored.

RESULTS

The most used treatment modalities were psychoeducation (n = 289, 86.5%) and follow-up in outpatient care (n = 192, 70.6%). A cross-sectoral collaboration was initiated for a third of cases (n = 98, 29.3%). The most commonly provided treatment combination consisted of psychoeducation, follow-up in outpatient care and psychotherapy; however, only a few patients received this specific combination (n = 14, 4.2%).

CONCLUSIONS

The treatment applied was individualized and consisted of varying use of treatment modalities. Initiatives to curate clinical guidelines and implement a multidisciplinary treatment approach should be further explored to improve treatment for this young group of patients.

Prospective multicenter cohort study of possible psychogenic nonepileptic seizure cases-Results at 1-year follow-up examinations

OBJECTIVE

The primary purpose of this prospective multicenter study was to examine clinical and demographic feature differences according to the diagnostic level of psychogenic nonepileptic seizures (PNES) and then clarify whether prognosis may also differ accordingly.

METHODS

Two hundred forty-two consecutive patients strongly suspected of having PNES attacks were invited to participate, of whom 52 did not consent or contact was lost. At the 1-year follow-up examination, PNES diagnosis was reconsidered in nine patients. In 96 patients, the diagnostic level remained the same (P-group), with that in 43 considered to be clinically established (CE-group) and in 42 documented (D-group). The Qolie-10 and NDDI-E questionnaires were examined at both the study entry and the follow-up examination.

RESULTS

Multiple regression analysis of quality of life (QoL) score (n = 173; R²  = 0.374; F = 7.349; P < 0.001) revealed NDDI-E score (t = -6.402; P < 0.001), age of PNES onset (t = -3.026; P = 0.003), and ethnic minority status (t = 3.068; P = 0.003) as significant contributors. At entry, the P-group showed the lowest PNES attack frequency (P < 0.000), the lowest rate of antiseizure, antidepressant, and antipsychotic medication (P < 0.000; P = 0.031; P = 0.013, respectively), and the lowest proportion of psychosis (P = 0.046). At follow-up, PNES attack frequency (P < 0.000), number of admittances to emergency room (P < 0.000), and scores for QoL (P < 0.000) as well as depression (P = 0.004) were found to be significantly improved together with other collateral indicators, such as rate of antiseizure medication prescription (P = 0.001) and psychiatric symptoms (P = 0.03). Multiple regression analysis of a sample limited to patients with intellectual disability (ID) (n = 44; R²  = 0.366; F = 4.493; P = 0.002) revealed continued psychotherapy at follow-up (t = 2.610, P = 0.013) and successful reduction in antiseizure medication (t = 2.868; P = 0.007) as positively related with improved QoL.

SIGNIFICANCE

Clinical and the socio-psychological constellation of possible, clinically established, and documented PNES were found to differ greatly. Unexpectedly, significant effects of the continuous psychotherapeutic intervention were confirmed in PNES patients with ID.

Functional neurological disorder in children and young people: Incidence, clinical features, and prognosis

AIM

To report incidence, demographic and clinical characteristics, and symptom outcome of functional neurological disorder (FND) in children.

METHOD

Children diagnosed with FND at a regional children's hospital were prospectively recruited by weekly active surveillance for 36 months. Demographic, clinical, and follow-up data were retrospectively extracted by review of electronic records. Descriptive statistical analyses were used.

RESULTS

Ninety-seven children (age range 5-15 years) met the case definition of FND (annual incidence 18.3 per 100 000 children). Children with FND were likely to be female (n = 68 [70%]) and older (median 13 years) with no difference in the Scottish Index of Multiple Deprivation (marker of socioeconomic status) compared with the general childhood population. Functional motor (41%) and sensory (41%) symptoms were most common; other somatic symptoms such as headache (31%) and pain (27%) were frequent. Self-reported psychiatric symptoms and infection/inflammation were the most common predisposing and precipitating factors respectively. At a median of 15 months follow-up, 49% of 75 children reported improvement or resolution of FND symptoms with no prognostic factors found.

INTERPRETATION

At this regional centre, FND in children had a higher incidence than previously reported and a less optimistic outcome than in some other studies.

Longitudinal outcome of Functional Neurological Disorder in Children and Adolescents in a Tertiary Care centre from Northern India

FND is common in Indian children and adolescents. Outcome related factors are not well known. With objective to study short-term outcome of FND, prospective, longitudinal, nine months follow-up study of 6-16 years was planned. Socioeconomic, clinical variables, I.Q. and personality traits at baseline and new psychiatric/physical illness, psychosocial factors and comorbidities during follow-up were assessed. Out of 68 children, scholastic (64.7%) and family problems (23.5%) were common psychosocial factors. After nine months,73% achieved remission. Reasons for non-remission were persistence of psychosocial factors and psychiatric comorbidities. A need arises for increasing awareness among general practitioners for early identification and management.

Improved understanding of non-epileptic seizures and reduced emergency health care usage following a single psychoeducational group for children and their parents

RATIONALE

The aim of this study was to evaluate the effectiveness of a three-hour psychoeducation group in improving understanding of non-epileptic seizures (NES), health outcomes and quality of life in young people with NES.

BACKGROUND

Multi-session psychoeducational groups for adults with NES have reported improved psychosocial functioning and reduced NES compared to those who do not receive psychoeducational interventions. To date there have been no studies in young people examining the effects of a single session of psychoeducation.

METHOD

15 young people with NES and their families attended a psychoeducation group within a specialist hospital following a multidisciplinary assessment. The group's effectiveness was evaluated in terms of perceptions of seizure controllability, seizure severity, the management of the condition and health-related quality of life measures.

RESULTS

A significant decrease in accident and emergency (A&E) visits and ambulance call outs was observed following the psychoeducation group. Young people additionally reported increased knowledge of NES and ability to cope with the condition which was maintained at 6-week follow-up. Significant reduction in NES occurrence or quality of life was not observed.

CONCLUSION

Significant reduction in A&E attendance and ambulance use was found following group psychoeducation and improvements in psychosocial functioning and knowledge about NES. Group psychoeducation has the potential to increase child and parental understanding of NES and reduce inappropriate healthcare usage.

Psychogenic nonepileptic seizures: clinical characteristics and outcome

BACKGROUND

Clinical characteristics, outpatient situation, and outcome in patients with psychogenic nonepileptic seizures (PNES) remain to be elucidated.

METHODS

Patients diagnosed with PNES after video-electroencephalography (EEG) monitoring (VEM) 03/2000-01/2016 at the Erlangen Epilepsy Center were surveyed between June 2016 and February 2017. Primary outcome was PNES cessation defined as no PNES episodes within > = 12 months prior to the interview. Secondary outcome variables included quality of life (QoL) and dependency. Sensitivity analysis included patients with proven PNES during VEM without comorbid epilepsy.

RESULTS

Ninety-nine patients were included (median age 38 (interquartile range (IQR 29-52)) years; 68 (69%) females, follow-up 4 (IQR 2.1-7.7) years). Twenty-eight (28%) patients suffered from comorbid epilepsy. Twenty-five (25%) patients reported PNES cessation. Older age at symptom onset (odds ratio (OR) related to PNES cessation: 0.95 (95% CI 0.90-0.99)), comorbid epilepsy (OR 0.16 (95% CI 0.03-0.83)), anxiety disorder (OR 0.15 (95% CI 0.04-0.61)), and tongue biting (OR 0.22 (95% CI 0.03-0.91)) remained independently associated with ongoing PNES activity after adjustment. Sensitivity analysis (n = 63) revealed depressive disorder (OR 0.03 (95% CI 0.003-0.34)) instead of anxiety as independent predictor, while this seemed relevant only in patients older than 26 years at onset (OR 0.04 (95% CI 0.002-0.78) versus OR 0.21 (95% CI 0.02-1.84) in patients  younger than 26 years). PNES cessation was associated with increased median QoL (8 (IQR 7-9) versus 5.5 (IQR 4-7); p < .001) and an increased frequency of financial independency (14 (56%) versus 21 (28%); p = .01).

CONCLUSIONS

We found poor outcomes in PNES especially in older patients at onset with comorbid depressive disorder. Comorbid epilepsy also seems to be a major risk factor of ongoing PNES activity, which in turn affects patients' daily living.

Treatment of Pediatric Functional Neurological Symptom Disorder: A Review of the State of the Literature

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.

The effectiveness of psychological interventions for children and adolescents with non-epileptic seizures

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.

Outcome of Conversion Symptoms in Children

The study evaluated the short-term outcome of children diagnosed with conversion disorder and compared their pre- and post-intervention psychological functioning. Fifty children consecutively diagnosed with conversion disorder over a period of one year were recruited from the pediatrics department of a tertiary care teaching hospital in North India. The adverse life events were assessed by the Life Events Scale for Indian Children, emotional and behavioral difficulties by the Childhood Psychopathology Measurement Schedule (CPMS), and adjustment by the Pre-Adolescent Adjustment Scale (PAAS). Majority of the children improved at follow up at 3 mo after initiation of treatment. In addition, total scores on the CPMS significantly declined (t = 5.12, P = 0.0001) and self-reported adjustment improved on the PAAS (t = 5.81, P = 0.0001) as compared to functioning before the initiation of therapy. Timely recognition and multi-disciplinary management can lead to successful outcome and improved functioning in most children diagnosed with conversion disorder.

Incidence rates and characteristics of pediatric onset psychogenic nonepileptic seizures

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

IMPACT

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

Psychogenic nonepileptic seizures in children-Prospective validation of a clinical care pathway & risk factors for treatment outcome

PURPOSE

The purpose of this study was to prospectively validate a care pathway for psychogenic nonepileptic seizures (PNES) in a pediatric setting. The pathway was developed based on a previous study of patients at our center, which demonstrated positive treatment outcomes of 80% full or partial remission. Sequentially referred patients with PNES in the validation cohort received care prospectively according to the pathway algorithm. It was hypothesized that the validation cohort would achieve outcomes similar to that of the development cohort as a result of standardized care.

METHOD

We performed a retrospective chart review of 43 children sequentially referred, assessed, and treated within a specialized neurology psychology service for suspected PNES over a 5-year period. The majority of patients (n = 41, 95%) met diagnostic criteria for probable, clinically established, or documented PNES, according to the International League Against Epilepsy (ILAE) criteria.

RESULTS

Ages ranged from 6 to 18 years of age at time of diagnosis, with the majority of patients being female (n = 29, 67%) and adolescent (n = 31, 72%). There was a high level of adherence to the care algorithm (n = 34, 84%). The development and validation cohorts were similar across demographic, clinical, and psychological characteristics. Standardized care resulted in high rates of full (n = 27, 63%) and partial (n = 12, 28%) remission, as self-reported at discharge. A 96% decrease in mean monthly frequency of total PNES events was also observed at discharge, as was a significant reduction in healthcare utilization related to PNES (74% fewer ambulance calls and 85% fewer emergency department (ED) visits). Post hoc analyses demonstrated that duration of PNES illness longer than 12 months (at diagnosis) increased odds of not achieving full remission by discharge (odds ratio = 5.94, p = 0.02). Developmental period of onset (child versus adolescent), having abnormal electroencephalogram (EEG) result, previous concussion, chronic versus acute stressor, more than one PNES event type, or additional functional neurological symptoms did not significantly impact treatment response.

CONCLUSIONS

This study demonstrates, for the first time prospectively in a pediatric setting, that standardized care for PNES leads to improved clinical outcomes and reduced healthcare utilization. Delayed diagnosis and treatment of PNES longer than 12 months also appears to be associated with less favorable outcomes in children.

School bullying: an increasingly recognized etiology for psychogenic non-epileptic seizures: report of two cases

Psychogenic non-epileptic seizures (PNES) are seizure-like episodes that are not associated with changes on electroencephalogram. They are the result of a wide range of possible psychological stressors including being a victim of bullying. Currently, reports regarding PNES in bullied patients are lacking. In this case report, we describe two cases; the first is a 10-year-old boy who presented to the emergency room once for visual loss and another for inability to walk. The other is a 12-year-old boy who has experienced recurrent episodes of loss of consciousness. Based on the negative investigations for any other possible diagnosis, and upon the nature of the episodes, a diagnosis of PNES was made after a history of bullying victimization was revealed. This suggests that PNES can result from psychological distress caused by school bullying victimization in children and highlights the importance of screening for bullying in patients with PNES.

Patient and family perspectives of paediatric psychogenic non-epileptic seizures: A systematic review

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.

Paediatricians' attitudes to and management of functional seizures in children

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.

Early outcomes in youth with psychogenic nonsyncopal collapse

Objective

To evaluate several early outcome measures following diagnosis of psychogenic nonsyncopal collapse (PNSC).

Methods

Over a 34-month period, a prospective cohort study was conducted of patients referred for tilt-table evaluation of fainting and orthostatic intolerance. Clinical histories were obtained and anxiety and depressive symptom questionnaires were completed prior to testing. Among 539 patients referred, 100 (18.6%) were diagnosed with PNSC. Outcome data were collected by telephone or during routine follow-up a median of 572 days postdiagnosis.

Results

Eighty-four patients (84%) provided outcome data. Following communication of the diagnosis, 32 patients (38%) had immediate PNSC resolution. Attack resolution occurred in 44% by 1 month, 51% by 6 months, 52% by 12 months, 69% after 12 months, and 31% continued to have PNSC at the time of follow-up. Patients with continued PNSC had higher anxiety scores than patients with immediate resolution (p = 0.047). Following diagnosis, emergency department visits for fainting decreased from 78.6% to 20.2% (p = 0.017), and management by psychology or psychiatry increased from 26.2% to 76.2% (p < 0.001). During the follow-up period, 8 patients (9.5%) were hospitalized for suicidal ideation, a median of 253 (range 33–470) days postdiagnosis; 12 patients (14.3%) developed new (non-PNSC) conversion disorders, a median of 86 (range 9–504) days postdiagnosis. Suicidal ideation was associated with higher anxiety (p = 0.007) but not higher depression scores.

Conclusions

The diagnostic rate of PNSC parallels that of PNES among patients referred for tertiary care evaluations. The improvements in attack frequency following PNSC diagnosis must be tempered by the potential risks of self-harm and the development of new conversion disorders.

An Overview of Psychogenic Non-Epileptic Seizures: Etiology, Diagnosis and Management

The purpose of this review is to provide an update of the research regarding the etiology, diagnosis and management of psychogenic non-epileptic seizures (PNES). A literature search using Pubmed, Ovid MEDLINE and EMBASE database was performed from 2000 up to August 2017. We have evaluated the different factors leading to PNES as well as the diagnostic approach and management of this disorder which continue to be very difficult. The coexistence of epilepsy and PNES poses special challenges and requires the coordinated efforts of the family physicians, psychiatrists, psychologists and neurologists. Although this condition has an overall poor prognosis, a multidisciplinary approach in the diagnosis and management of this disorder would likely improve the outcomes. We have proposed a diagnostic and treatment algorithm for PNES and suggested a national registry of patients suffering from this condition. The registry would contain data regarding treatment and outcomes to aid in the understanding of this entity.

Pediatric Psychogenic Nonepileptic Seizures: A Concise Review

Psychogenic nonepileptic seizures is a complicated biopsychosocial disorder with significant morbidity and high cost in children's social, emotional, family, and academic functioning as well as health care service utilization. Misdiagnosis and diagnostic delay, resulting from both lack of access to approved standards for diagnosing and service providers comfortable with diagnosing and treating this disorder, impact prognosis. Treatment in close proximity to symptom onset is thought to provide the best chance for remission.

Clinical Approaches to Psychogenic Nonepileptic Seizures

Psychogenic nonepileptic seizures (PNES) are a subtype of conversion disorder (also called functional neurological symptom disorder in DSM-5). Patients with PNES are high utilizers of health care and can have disability levels similar to those of patients with epilepsy. PNES is a common, complex neuropsychiatric somatoform disorder at the interface of neurology and psychiatry disciplines and is largely overlooked and avoided by mental health providers. Despite advances in establishing accurate diagnosis and evidence-based treatments, recent knowledge about PNES has not been well translated into clinical practice. Long diagnostic delays have been associated with poor prognosis. Recent advances in possible neurophysiological biomarkers include functional MRI studies that show abnormalities in emotional, cognitive, executive, and sensorimotor neurocircuits. Although the gold standard for diagnosis is video electroencephalograph, this test is underused by psychiatrists. The International League Against Epilepsy proposed a staged approach to PNES diagnosis using history, semiologic features, and EEG. Thorough psychiatric assessment can identify relevant biopsychosocial and predisposing, precipitating, and perpetuating factors, as well as assess the comorbid psychiatric disorders, which can inform a treatment plan. Clear and thoughtful delivery of diagnosis is the first step in treatment. Regular follow-up with the patient's neurologist, in addition to treatment by mental health professionals familiar with somatic symptom disorders, is recommended. Psychotherapy is the mainstay of treatment, and randomized clinical trials using cognitive-behavioral therapies reveal significant reduction in seizures and other psychiatric symptoms. After centuries, mental health providers now have access to the tools to diagnose and effectively treat PNES and other conversion disorders.

Social participation in young people with nonepileptic seizures (NES): A qualitative study of managing legitimacy in everyday life

This qualitative study explored social participation in young people with nonepileptic seizures (NES), particularly how legitimacy of illness is managed in everyday life. Young people with NES, all female and aged between 14 and 24 years (N=11), were interviewed and followed up over a 14-month period. The transcripts were analyzed using thematic analysis. Four main themes were elaborated: 1) Delegitimizing experiences from families, schoolteachers, colleagues, and employers were part of everyday life. 2) Fear of being exposed to delegitimizing events resulted in the young people trying to conceal the diagnosis; for some, this resulted in isolation from all social arenas, apart from their closest relationships. 3) Support from close relationships was protective against delegitimization and contributed towards greater social participation. 4) Perceiving NES as a legitimate disorder contributed to increased social participation. We found a relationship between legitimacy of illness experienced by the participants and the extent to which they either participated or retreated socially. Those who had an illness perception that was personally meaningful experienced their condition as being more legitimate and participated more socially.

Psychogenic seizures: long-term outcome in patients with and without epilepsy

OBJECTIVES

Psychogenic non-epileptic seizures (PNES) may resemble epileptic events. Epileptic and non-epileptic seizures are not mutually exclusive phenomena and may coexist in the same patient. The aim of this study was to evaluate the long-term outcome of psychogenic events in patients with PNES alone and those with both PNES and epilepsy (PNES + EPI) as diagnosed by video-EEG (vEEG) monitoring.

MATERIALS AND METHODS

All adult admissions to the Tel-Aviv Medical Center's vEEG unit between 2004 and 2009 were screened for the presence of PNES. We retrospectively retrieved data from their medical files and supplemented the follow-up by a telephonic questionnaire.

RESULTS

Eligible patients (n = 51) were divided into those with PNES + EPI (n = 24) and those with PNES alone (n = 27). The follow-up period was 4.8 ± 0.3 and 4.3 ± 0.3 years, respectively. Both groups had similar female predominance and similar age at admission to the vEEG unit. Time from PNES onset to hospitalization was longer in PNES patients compared to those with PNES + EPI. The majority of subjects in each group reported a history of at least one major stressful life event. Opisthotonus was significantly more frequently observed in PNES patients, and they had more events during vEEG hospitalization. Psychogenic events ceased during the follow-up period in 22% of the PNES patients and in 58% of the PNES + EPI patients (P > 0.001).

CONCLUSION

Our results indicate that following vEEG-based diagnosis of PNES, the long-term outcome of PNES cessation may be more favorable for patients with concomitant epilepsy than for patients without epilepsy.

Psychogenic nonepileptic seizures as a manifestation of psychological distress associated with undiagnosed autism spectrum disorder

Psychogenic nonepileptic seizures (PNES) are observable changes in behavior or consciousness that are similar to epileptic seizures but are not associated with electrophysiologic changes. PNES occur in children with underlying psychological distress and are especially frequent in those with epilepsy. Because PNES are heterogeneous, comprehensive treatment tailored to each patient is required to reduce psychosocial stress. Currently, reports regarding children with PNES concomitant with autism spectrum disorder (ASD) do not exist, and effective treatment strategies for these children are lacking. In this case report, we describe a 10-year-old Japanese girl with undiagnosed ASD who developed PNES while undergoing treatment for benign childhood epilepsy with centrotemporal spikes. She exhibited hypersensitivity to sound and interpersonal conflicts caused by social communication deficits. The PNES symptoms improved shortly after our intervention, which was designed to reduce her distress caused by auditory hypersensitivity and impaired social communication, both characteristics of ASD. To the best of our knowledge, this is the first report describing PNES in a child with ASD. Our findings suggest that PNES can result from psychological distress in children with undiagnosed ASD and highlight the importance of examining ASD traits in patients with PNES.

Outcome of psychogenic nonepileptic seizures (PNES) in children: A 2-year follow-up study

OBJECTIVE

The objective of this study was to determine the outcome of psychogenic nonepileptic seizures (PNES) in children seen at a level 4 epilepsy center.

METHODS

We retrospectively analyzed patients under the age of 18 years who were diagnosed with PNES based on evaluation in the epilepsy monitoring unit and had a follow-up of at least 2 years postdiagnosis. Remission of events was noted at 6 months, 12 months, and 24 months of follow-up, and patient and disease variables affecting outcome were studied.

RESULTS

Ninety patients met inclusion criteria (58 females; mean age: 14.03 ± 3.3 years). Thirty-two out of ninety (36%) patients had early (within 6 months) and sustained remission (until 2 years of follow-up) of their events ("favorable outcome"), while 30/90 patients (33%) never achieved remission during the study period ("unfavorable outcome"). The factors that were associated with "unfavorable outcome" included the presence of comorbid epilepsy [12/30 (40%) vs 0/32, p<0.0001] and prolonged duration of symptoms before establishment of the diagnosis (median 365 days vs 60 days, p<0.0001). Patient's age, gender, frequency of events, the presence of major psychosocial stressors, and comorbid psychiatric conditions had no significant impact on the disease outcome.

CONCLUSIONS

About a third of children with PNES achieve early and sustained remission of symptoms, while another third continue to manifest seizure-like events until at least two years after the diagnosis. The presence of comorbid epilepsy and prolonged duration of PNES are associated with a poor two-year outcome. Early suspicion and diagnosis of PNES, especially in patients with epilepsy, is essential.

Psychogenic nonepileptic seizures in children - Psychological presentation, treatment, and short-term outcomes

PURPOSE

The purpose of this study was to better understand the etiologies, features, and care outcomes of psychogenic nonepileptic seizures (PNESs) in a pediatric setting.

METHOD

We performed a retrospective analysis of 32 sequentially referred children for suspected PNESs to a neurology psychology service over a 6-year period. After excluding non-PNES paroxysmal events (related to anxiety or migraine), 29 patients were identified with final diagnosis of PNESs. Charts were examined for presenting symptom data, demographics, comorbidities, neurological diagnoses and investigations, as well as psychological assessment, management, and outcome. Treatment consisted of education around diagnosis and of individual psychological treatment, which, in most cases, was cognitive behavioral therapy up to 14 sessions. Additional mental health services including psychiatric medication, family therapy, and admission to day or inpatient treatment were also utilized in a smaller number of cases. Total treatment periods ranged from 4 weeks to 12 months.

RESULTS

The majority of patients identified were adolescent (90%), Caucasian (72%), and female (76%). Preceding psychology referral, point of entry into medical care for PNESs was primarily through the emergency department (66%) or outpatient neurology clinic referral (31%). Whereas 39% of parents described significant internalizing symptoms in their child (BASC-2), patients themselves tended to underreport anxiety or depression as demonstrated by only 16% endorsement on the BYI-II. By contrast, MACI personality assessment response patterns for adolescents demonstrated high levels of psychic tension/anxiety (65%), depressive affect (55%), and maladaptive personality traits including inhibition (45%), submissiveness (35%), and introversion (30%). Appropriate psychological treatment was associated with high rates of full remission (no new events, n=17, 59%) and partial remission (50% or greater reduction in events, n=6, 21%) as self-reported at discharge. Accurate diagnosis and referral to psychology also led to a sevenfold reduction in PNES-related emergency department visits one year after initial psychology visit compared with the preceding year.

CONCLUSIONS

This study suggests that appropriate care for PNESs reduces inappropriate medical investigation and therapy, expedites rates of remission, and decreases health-care utilization in a pediatric setting.

Models of hypoxia and ischemia-induced seizures

Despite greater understanding and improved management, seizures continue to be a major problem in childhood. Neonatal seizures are often refractory to conventional antiepileptic drugs, and can result in later life epilepsy and cognitive deficits, conditions for which there are no specific treatments. Hypoxic and/or ischemic encephalopathy (HIE) is the most common cause for neonatal seizures, and accounts for more than two-thirds of neonatal seizure cases. A better understanding of the cellular and molecular mechanisms is essential for identifying new therapeutic strategies that control the neonatal seizures and its cognitive consequences. This heavily relies on animal models that play a critical role in discovering novel mechanisms underlying both epileptogenesis and associated cognitive impairments. To date, a number of animal models have provided a tremendous amount of information regarding the pathophysiology of HIE-induced neonatal seizures. This review provides an overview on the most important features of the main animal models of HIE-induced seizures. In particular, we focus on the methodology of seizure induction and the characterizations of post-HIE injury consequences. These aspects of HIE-induced seizure models are discussed in the light of the suitability of these models in studying human HIE-induced seizures.

A Therapeutic Approach to Psychogenic Nonepileptic Seizures

OPINION STATEMENT

The diagnosis of psychogenic nonepileptic seizures (PNES) is usually made in the seizure monitoring unit (SMU; also commonly named the epilepsy monitoring unit) after PNES are recorded on video-EEG. The diagnosis should be discussed with the patient thoroughly. The discussion should focus on how the diagnosis was reached and that the diagnosis is real and treatable. When the diagnosis is communicated well, some patients may improve significantly without further interventions. Next, a psychiatric evaluation should be completed, ideally before discharge from the SMU. After discharge, the patient should undergo cognitive behavioral therapy (CBT), the only treatment for PNES that is supported by high-quality evidence. Other therapies, including psychodynamic therapy and different types of group therapy can be considered in some patients, although high-level evidence to support their use is lacking. Some patients may benefit from selective serotonin-reuptake inhibitors (SSRIs), especially when psychiatric comorbidities are present. This should be considered on a case-by-case basis.

Semiological and psychiatric characteristics of children with psychogenic nonepileptic seizures: Gender-related differences

PURPOSE

To compare semiological characteristics, precipitating stress factors and psychiatric diagnoses of girls and boys with psychogenic nonepileptic seizures (PNESs).

METHODS

We retrospectively reviewed medical records of children diagnosed with PNES and who also underwent psychiatric evaluation. Sixty-two children (44 girls, 18 boys), aged 11-18 years (mean age 14.19 ± 1.96 years) were included. Diagnosis of PNES was established by any of the following: (1) observation of the seizure by a neurologist and routine EEG, (2) evaluation of amateur video records of the typical seizure and routine EEG, or (3) video-EEG monitoring. Psychiatric examinations of patients were performed using the Schedule for Affective Disorders and Schizophrenia for School Age Children-Present and Lifetime Version (KSADS-PL).

RESULTS

Tremor was the most prevalent ictal motor sign in both girls and boys. Atonic falls and longer episodes were significantly more frequent in girls than boys. Tonic-clonic-like movements of the extremities were significantly more prevalent in boys than girls. No gender-specific differences were observed in the rates of semiological types. Academic underachievement was the most prevalent precipitating stressor for boys, and was significantly more prevalent in boys than girls. The rate of major depression was significantly higher in girls than boys. The most prominent diagnosis in boys was attention deficit/hyperactivity disorder, and this was significantly more prevalent than in girls.

CONCLUSION

PNES in males of juvenile age may be a distinct entity from that in girls with different semiological and psychogenic correlates. Consideration of these gender-related differences may be beneficial for the early recognition and treatment of PNES.

Psychogenic Paroxysmal Nonepileptic Events in Children: A Review

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Diagnosis of probable psychogenic nonepileptic seizures in the outpatient clinic: does gender matter?

Psychogenic nonepileptic seizures (PNESs) are paroxysmal events of altered behavior that outwardly resemble epilepsy but are caused by psychiatric disease. The diagnosis of probable PNESs can be made in the outpatient clinic prior to video-EEG monitoring by identification of specific PNES predictors and specific elements of seizure semiology from the clinical history. Since psychiatric disease may have distinct mechanisms between women and men, the objective of this study was to determine if gender-specific differences exist in PNES predictors and PNES semiology. Such differences could be used to optimize the accuracy of outpatient diagnosis of probable PNESs. Medical records of male and female patients with video-EEG diagnosis of definite PNESs were retrospectively reviewed for occurrence of PNES predictors. In addition, PNES semiology was analyzed de novo from video-EEG records and categorized into previously established semiology clusters. Eighty-six patients were included in the analysis (59 women and 27 men). We found significantly lower rates of reported physical and sexual abuse, lower rates of previous psychiatric diagnosis, and lower rates of chronic pain in male patients with no significant differences in rates of other PNES predictors. Furthermore, we found no difference in PNES semiology between men and women, with both groups experiencing similar rates of major motor, minor motor, and nonmotor semiology. In conclusion, our results lend support to the idea that distinct risk factor criteria but similar semiology criteria should be used for the diagnosis of probable PNESs in the outpatient clinic in men and women.

Clinical profile of psychogenic non-epileptic seizures in adults: A study of 63 cases

AIMS

To evaluate clinical profile and short-term outcome of psychogenic non-epileptic seizures (PNES) in Indian adult population.

SETTING AND DESIGN

A prospective observational study, conducted at tertiary teaching institute at New Delhi.

MATERIALS AND METHODS

Sixty-three patients with confirmed PNES were enrolled. The diagnosis was based on witnessing the event during video-electroencephalography (Video-EEG) monitoring. A detailed clinical evaluation was done including evaluation for coexistent anxiety or depressive disorders. Patients were divided into two groups on the basis of excessive or paucity of movements during PNES attacks. Patients were followed-up to 12 months for their PNES frequency.

STATISTICAL ANALYSIS

Means and standard deviations were calculated for continuous variables. Chi-square and Students t-test were used to compare categorical and continuous variables respectively.

RESULTS

The mean age at onset of PNES was 25.44 years; with F:M ratio of 9.5:1. Coexistent epilepsy was present in 13 (20.63%) cases. Twenty-two patients (44%) with only PNES (n = 50) had received antiepileptic drugs. Out of 63 patients of PNES 24 (38.1%) had predominant motor phenomenon, whereas 39 (61.9%) had limp attacks. The common features observed were pre-ictal headache, ictal eye closure, jaw clenching, resistant behavior, ictal weeping, ictal vocalization, and unresponsiveness during episodes. Comorbid anxiety and depressive disorders was seen in 62.3% and 90.16% patients, respectively. Short-term (6-12 months) outcome of 45 patients was good (seizure freedom in 46.66% and >50% improvement in 24.44% cases).

CONCLUSION

PNES is common, but frequently misdiagnosed and treated as epileptic seizures. A high index of suspicion is required for an early diagnosis. Proper disclosure of diagnosis and management of the psychiatric comorbidities can improve their outcome.

LIMITATION

Limited sample size and change in seizures frequency as the only parameter for the assessment of the outcome are the two major limitations of our study.

Psychogenic nonepileptic seizures

Psychogenic nonepileptic seizures (PNES) are clinical events resembling epileptic seizures but lacking abnormal cortical electrical discharges. They are involuntary manifestations of a psychological distress. PNES are less frequent in the pediatric population than in adults, they represent from 3.5 to 9% of patients admitted for prolonged video-EEG (PV-EEG). Diagnosis is rarely made on history only and PV-EEG is mandatory to obtain a definitive diagnosis. Children as young as 5 years can present with PNES. They are more frequent in girls except in school age children where boys are identically or more represented than girls. PNES can either present with subtle signs, even unresponsiveness, or prominent motor activity. Major differential diagnosis is absences, day dreaming, and complex partial seizures including hyperkinetic frontal seizures. PNES are usually rapidly registered during PV-EEG and provocative methods have not been thoroughly studied in children. Major risk factors are psychological stressors, such as school or family problems. Psychiatric conditions are less frequent than in adults though they should be looked for. Prognosis is better than in adults, and most children become PNES-free. There are no guidelines for treatment, however stressors should be addressed. In general, it should be clearly explained that PNES are not epileptic seizures.

A detailed semiologic analysis of childhood psychogenic nonepileptic seizures

PURPOSE

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

METHODS

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

KEY FINDINGS

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

SIGNIFICANCE

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

Clinical and psychosocial characteristics of children with nonepileptic seizures

Objective:

The aim of this study is to present a comprehensive profile of clinical and psychosocial characteristics of children with psychogenic nonepileptic seizures and to assess the short-term outcome of these patients.

Materials and Methods:

The subjects were consecutive cases of children with a diagnosis of nonepileptic seizures (N=17, mean age = 10.7 years, S.D. = 1.26) and two groups of control groups matched on age and sex: true seizure group and healthy controls. All the children were recruited from the out-patient services of the Department of Pediatrics of a tertiary care teaching hospital in North India. Detailed history taking and clinical examination was done in the case of every child. A standard 18 channel EEG was done in all the children and a video EEG was done in 12 cases of children with nonepileptic seizures. The Childhood Psychopathology Measurement Schedule (CPMS) and Life Events Scale for Indian Children (LESIC) were used to measure the children's emotional and behavioral functioning at home, and the number of life events and the stress associated with these events in the preceding year and the year before that. Short-term outcome was examined three to six months after the diagnosis of nonepileptic seizures was made.

Results:

Unresponsiveness without marked motor manifestations was the most common “ictal” characteristic of the nonepileptic seizures. Pelvic thrusting, upper and lower limb movements, head movements, and vocalization were observed in less than one-third of the patients. Increased psychosocial stress and significantly higher number of life events in the preceding year were found to characterize children with nonepileptic seizures, as compared to the two control groups. The nonepileptic seizures and true seizures groups had a higher proportion of children with psychopathology scores in the clinically significant maladjustment range, as compared to those in the healthy control group. A majority of the patients (82.4%) either recovered completely or had more than 50% reduction in the frequency of their symptoms, after three to six months of initiation of therapy.

Conclusions:

Psychosocial stress is common among children with nonepileptic seizures. Confirmatory diagnosis by video EEG, along with prompt psychosocial intervention, often results in a favorable outcome for most children with nonepileptic seizures.

Prognosis and outcome predictors in psychogenic nonepileptic seizures

It is estimated that one in five patients referred to specialist epilepsy clinics for refractory seizures have psychogenic nonepileptic seizures (PNES). Despite the high prevalence, little is known about the prognosis of patients with PNES. In this paper we set out to systematically assess published original studies on the prognosis and outcome predictors of patients with PNES. Our literature search across the databases Medline, PsycINFO, and EMBASE generated 18 original studies meeting the search criteria. Prognosis was found to be poor in adults, but good in children. Predictors of poor outcome included the presence of coexisting epilepsy or psychiatric comorbidities, violent seizure phenomenology, dependent lifestyle, and poor relationships. Overall, too much reliance is placed on seizure remission as an outcome measurement for patients with PNES, and the impact of many of the outcome predictors requires evaluation using larger studies with longer followup.

Clinical characteristics and outcome in patients with psychogenic nonepileptic seizures

OBJECTIVES

To examine baseline clinical features of psychogenic nonepileptic seizures (PNES) in a large cohort and to investigate outcome over a period of up to 10 years. Studies investigating PNES have been limited by differences in diagnostic criteria, short follow-up periods, and the use of limited outcome measures.

METHOD

Patients with PNES were identified, using strict diagnostic criteria. Baseline neurological, neuropsychiatric, and neuroimaging data were obtained from medical records. Long-term outcome was assessed with ratings of seizures, psychopathology, and quality of life in a subset of the patients.

RESULTS

Patients with PNES (n = 221) experienced long delays in diagnosis (mu, 5.6 years; standard deviation, 7.7 years) and high rates (>60%) of prolonged treatment with antiepileptic drugs. Compared with previous studies, a relatively low proportion (8.1% to 17.9%, depending on diagnostic criteria) had comorbid epilepsy. An unexpected finding was that 22.6% of PNES patients had magnetic resonance imaging abnormalities. Patients assessed at follow-up (n = 61) exhibited poor long-term outcomes with ongoing PNES, high rates of psychopathology, low rates of specialist follow-up, poor quality of life, and poor overall levels of functioning.

CONCLUSIONS

These results demonstrate the need for earlier diagnosis of PNES and comorbidities and highlight the need for diagnostic and therapeutic approaches that combine neurological and psychiatric perspectives.

[Management of the first nonfebrile seizure in infants and children]

Seizures are the most common pediatric neurologic disorder. This article describes the guidelines of the French Pediatric Neurology Society, highlighting the importance of a thorough history and examination. Paroxysmal nonepileptic events should be excluded. The role of biological and neuroradiological investigations is discussed. An electroencephalographic recording and advice from a pediatric neurologist are suggested.

High prevalence of depression among Iranian patients with first onset pseudoseizures

BACKGROUND

Pseudoseizures are common and can pose a significant diagnostic and therapeutic challenge. Exploring the role of psychiatric disorders can be helpful. The aim of this study was to evaluate depression in patients with first onset pseudoseizure.

MATERIALS AND METHODS

Consecutive patients with pseudoseizure (DSM IV) in an emergency room (Tabriz, northwestern Iran) were evaluated with beck depression inventory (BDI) and were compared to age- and sex-matched patients with other neurologic disorders.

RESULTS

Forty-two patients with pseudoseizure (52% male; age: 25.7 +/- 6.4) were compared to 50 patients with other neurologic disorders (55.1% male; age: 27.2 +/- 5.7) by BDI. Marriage status and educational level were almost similar between two groups. The mean (+/-SD) score of BDI in patients with pseudoseizures and controls was 23.6 +/- 7.4 and 14.14 +/-10.5, respectively. Depression was more common and more severe among patients with pseudoseizures (96% vs. 60%).

CONCLUSION

Depression is common among patients with pseudoseizure even in patients with first onset attacks.

Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence

BACKGROUND

In the majority of cases short-term treatment outcome of juvenile dissociative disorder is rather favourable. In contrast, the long-term course seems to be less positive, but meaningful results are still fragmentary. The aim of this follow-up study is to bridge this gap to some extent describing the long-term outcome of juvenile dissociative disorder in a clinical sample. To our knowledge there is no comparable other long-term follow-up study which is based on a case definition according to actual classification systems using standardized interviews for individual assessment of the patients at the time of follow-up.

METHODS

The total study group was made up of all patients treated for dissociative disorder at our department for child and adolescent psychiatry between 1983 and 1992 (N = 62). Two of these former patients committed suicide during the follow-up period (3%). We got information on the clinical course of 27 former patients (44%). 17 out of these 27 former patients were female (63%). The mean age of onset of dissociative disorder was 11.7 years and the mean follow-up time was 12.4 years. Most of the patients were reassessed personally (n = 23) at a mean age of 24.8 years using structured interviews covering dissociative disorders, other Axis I disorders and personality disorders (Heidelberg Dissociation Inventory HDI; Expert System for Diagnosing Mental Disorders, DIA-X; Structured Clinical Interview for DSM-IV, SCID-II). Social adjustment was assessed by a semi-structured interview and by patient self report (Social Adjustment Scale - Self Report, SAS-SR). Psychosocial outcome variables were additionally assessed in 36 healthy controls (67% female, mean age = 22.9 years).

RESULTS

At the time of follow-up investigation 82.6% of the patients met the criteria for some form of psychiatric disorder, while 26.1% were still suffering from dissociative disorder. A total of 56.5% presented with an Axis I disorder (especially anxiety, dissociative and somatoform disorders). Personality disorders were seen in 47.8% (especially borderline, obsessive-compulsive and negativistic personality disorders). More dissociative symptoms and inpatient treatment in childhood or adolescence were significantly related to a lower level of psychosocial adjustment in adulthood.

CONCLUSION

Treatment strategies have to consider that in a significant portion of young patients initial recovery may not be stable over time. Limitations of the study refer to the small sample size and the low rate of former patients taking part in the follow-up investigation.

Psychogenic nonepileptic seizures: answers and questions

Psychogenic nonepileptic seizures (PNES) superficially resemble epileptic seizures, but are not associated with ictal electrical discharges in the brain. PNES constitute one of the most important differential diagnoses of epilepsy. However, despite the fact they have been recognized as a distinctive clinical phenomenon for centuries and that access to video/EEG monitoring has allowed clinicians to make near-certain diagnoses for several decades, our understanding of the etiology, underlying mental processes, and, subsequently, subdifferentiation, nosology, and treatment remains seriously deficient. Emphasizing the clinical picture throughout, the first part of this article is intended to "look and look again" at what we know about the epidemiology, semiology, clinical context, treatment, and prognosis of PNES. The second part is dedicated to the questions that remain to be answered. It argues that the most important reason our understanding of PNES remains limited is the focus on the visible manifestations of PNES or the seizures themselves. In contrast, subjective seizure manifestations and the biographic or clinical context in which they occur have been relatively neglected.

Nonepileptic Seizures in Children

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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