Treatment resistant epilepsy or convulsive syncope?

Specific biases for identifying facial expression of emotion in children and adolescents with conversion disorders

OBJECTIVE

This study aimed to assess how children and adolescents with conversion disorders identify universal facial expressions of emotion and to determine whether identification of emotion in faces relates to subjective emotional distress.

METHODS

Fifty-seven participants (41 girls and 16 boys) aged 8.5 to 18 years with conversion disorders and 57 age- and sex-matched healthy controls completed a computerized task in which their accuracy and reaction times for identifying facial expressions were recorded. To isolate the effect of individual emotional expressions, participants' reaction times for each emotion (fear, anger, sadness, disgust, and happiness) were subtracted from their reaction times for the neutral control face. Participants also completed self-report measures of subjective emotional distress.

RESULTS

Children/Adolescents with conversion disorders showed faster reaction times for identifying expressions of sadness (t(112) = -2.2, p = .03; 444 [609] versus 713 [695], p = .03) and slower reactions times for happy expressions (t(99.3) = 2.28, p ≤ .024; -33 [35] versus 174 [51], p = .024), compared with controls (F(33.75, 419.81) = 3.76, p < .001). There were no significant correlations (at the corrected p value of .01) between reaction times and subjective reports of perceived distress (r values ranged from 092 to 0.221; p > .018). There were also no differences in identification accuracy for any emotion (p > .82).

CONCLUSIONS

The observation of faster reaction times to sad faces in children and adolescents with conversion disorders suggests increased vigilance and motor readiness to emotional signals that are potential threats to self or to close others. These effects may occur before conscious processing.

[Convulsive syncope: characteristics and reproducibility using the tilt test]

OBJECTIVES

To establish the main clinical characteristics of convulsive syncope and the usefulness of the tilt test in its diagnosis.

METHODS

A total of 317 patients (aged 5-18 years old) under clinical suspicion of neurocardiogenic syncope underwent a multiparametric tilt test. Our tilt test protocol includes continuous noninvasive measurement of heart rate, blood pressure, and arterial oxygen saturation, as well as continuous noninvasive measurement of cerebral oxygen saturation by near-infrared spectrophotometry. In selected patients, simultaneous electroencephalogram (EEG) was performed.

RESULTS

The tilt test was positive in 216 patients (68.1 %). Of these, 25 (11.6 %) showed seizures during the test (convulsive syncope). Convulsions were asymmetric-tonic in 15 patients (60 %), generalized tonic in 5 (20 %), and tonic-clonic in 5 (20 %). In all patients, convulsive episodes lasted less than 30 seconds and spontaneously ceased upon placing the patient in a horizontal or Trendelenburg position. When simultaneous EEG was performed, diffuse brain wave slowing was observed, without paroxysmal activity.

CONCLUSIONS

Convulsive syncope is not an uncommon event in children and is easily elicited by means of the tilt test. Pediatricians should be aware of this finding in order to avoid the frequently established unidirectional association between seizures and epileptic disorders. Consequently, the tilt test should be considered an essential tool in the differential diagnosis between convulsive syncope and epilepsy.

Setting up a falls and syncope service for the elderly

Establishing a neurocardiovascular investigation unit for the investigation of falls and syncope in the elderly is feasible. With the increasing growth in the elderly population, these units will be required to play an equally increasing role in both the clinical management of patients and the ongoing clinical research into the conditions that cause falls and blackouts in the elderly.

The practice nurse's role in the management of epilepsy

Epilepsy is a serious and common neurological condition of which the medical, psychological and social implications are far-reaching. This article aims to discuss the practice nurse's role in responding to the needs of clients with epilepsy. This is explored from a primary health care perspective, focusing on nursing interventions and implications for practice. The potential exists for community nursing intervention to improve quality of life for clients through responsive service provision and by challenging the inequality that appears to exist with regard to it. The available research is overtly pharmacological in origin and nursing research in this field is extremely sparse.

Observations on recurrent syncope and presyncope in 641 patients

BACKGROUND

Syncope is a common disorder that is potentially disabling and affects both young and old. Once neurological, cardiological, and metabolic causes have been excluded, there remains a group in which diagnosis is unclear; some may have an autonomic basis. We therefore did a retrospective study on consecutive patients referred to our tertiary referral autonomic centres between 1992 and 1998 with recurrent syncope and presyncope, in whom non-autonomic causes, before referral, had been sought and excluded. The object was to find out whether autonomic investigation helped diagnosis.

METHODS

Data from case notes and from the autonomic database on 641 patients were analysed. Syncopal patients with a known or provisional diagnosis of autonomic failure were excluded from analysis. The role of screening tests in establishing or excluding an autonomic cause was assessed. Response to additional autonomic tests (such as head-up tilt with or without venepuncture, and food challenge and exercise) was documented. Some patients underwent further testing if non-autonomic neurological, psychiatric, and other disorders were considered.

FINDINGS

Screening autonomic function tests indicated orthostatic hypotension and confirmed chronic autonomic failure in 31 (4.8%) patients. Neurally mediated syncope was diagnosed in 279 (43.5%) on the basis of clinical features and autonomic testing. Most had vasovagal syncope (227 [35%]); other causes included carotid sinus hypersensitivity (37 [5.8%]), and a group of 15 (2.3%) were associated with rarer causes such as micturition and swallowing. Miscellaneous cardiovascular causes (systemic hypotension, arrhythmias), or drugs, contributed to syncope in 53 (8.3%). Non-autonomic neurological causes included vestibular dysfunction (32 [5%]) and epilepsy (11 [1.7%]). In 56 (8.7%) a psychiatric cause was thought to be contributory. In 179 (27.9%), syncope was of unknown cause.

INTERPRETATION

In recurrent syncope and presyncope, when cardiac, neurological, and metabolic causes have been excluded, autonomic investigation can aid management by making, confirming, or excluding various factors or diagnoses.