Psychogenic seizures after head injury in children

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.

An objective score to identify psychogenic seizures based on age of onset and history

OBJECTIVE

Psychogenic nonepileptic seizure (PNES) is a common diagnosis after evaluation of medication resistant or atypical seizures with video-electroencephalographic monitoring (VEM), but usually follows a long delay after the development of seizures, during which patients are treated for epilepsy. Therefore, more readily available diagnostic tools are needed for earlier identification of patients at risk for PNES. A tool based on patient-reported psychosocial history would be especially beneficial because it could be implemented in the outpatient clinic.

METHODS

Based on the data from 1375 patients with VEM-confirmed diagnoses, we used logistic regression to compare the frequency of specific patient-reported historical events, demographic information, age of onset, and delay from first seizure until VEM in five mutually exclusive groups of patients: epileptic seizures (ES), PNES, physiologic nonepileptic seizure-like events (PSLE), mixed PNES plus ES, and inconclusive monitoring. To determine the diagnostic utility of this information to differentiate PNES only from ES only, we used multivariate piecewise-linear logistic regression trained using retrospective data from chart review and validated based on data from 246 prospective standardized interviews.

RESULTS

The prospective area under the curve of our weighted multivariate piecewise-linear by-sex score was 73%, with the threshold that maximized overall retrospective accuracy resulting in a prospective sensitivity of 74% (95% CI: 70-79%) and prospective specificity of 71% (95% CI: 64-82%). The linear model and piecewise linear without an interaction term for sex had very similar performance statistics. In the multivariate piecewise-linear sex-split predictive model, the significant factors positively associated with ES were history of febrile seizures, current employment or active student status, history of traumatic brain injury (TBI), and longer delay from first seizure until VEM. The significant factors associated with PNES were female sex, older age of onset, mild TBI, and significant stressful events with sexual abuse, in particular, increasing the likelihood of PNES. Delays longer than 20years, age of onset after 31years for men, and age of onset after 40years for women had no additional effect on the likelihood of PNES.

DISCUSSION

Our promising results suggest that an objective score has the potential to serve as an early outpatient screening tool to identify patients with greater likelihood of PNES when considered in combination with other factors. In addition, our analysis suggests that sexual abuse, more than other psychological stressors including physical abuse, is more associated with PNES. There was a trend of increasing frequency of PNES for women during childbearing years and plateauing outside those years that was not observed in men.

Psychogenic non-epileptic seizures: aetiology, diagnosis and management

Psychogenic non-epileptic seizures (PNES) have a significant impact on most patients in terms of distress, disability, loss of income and iatrogenic harm. Three-quarters of patients with PNES are initially misdiagnosed and treated for epilepsy. Misdiagnosis exposes patients to multiple iatrogenic harms and prevents them from accessing psychological treatment. In most cases, the patient's history (and witness accounts) should alert clinicians to the likely diagnosis of PNES. Since this diagnosis may be resisted by patients and may involve ‘un-diagnosing’ epilepsy, video-electroencephalogram recording of typical seizures is often helpful. The underlying causes of PNES are diverse: a model combining predisposing, precipitating and perpetuating factors is a useful way of conceptualising their aetiology. The initial step of treatment should be to limit iatrogenic harm. There is some evidence for the effectiveness of psychotherapy.

Prevalence of epileptic and nonepileptic events after pediatric traumatic brain injury

Though posttraumatic epilepsy (PTE) is a prominent sequela of traumatic brain injury (TBI), other nonepileptic phenomena also warrant consideration. Within two UCLA pediatric TBI cohorts, we categorized five spell types: 1) PTE; 2) Epilepsy with other potential etiologies (cortical dysplasia, primary generalized); 3) Psychopathology; 4) Behavior misinterpreted as seizures; and 5) Other neurologic events. The two cohort subsets differed slightly in injury severity, but they were otherwise similar. Overall, PTE occurred in 40%, other epilepsy etiologies in 14%, and nonepileptic spells collectively in 46%. Among children with spells, PTE was associated with severe TBI (p=0.001), whereas psychopathology (p=0.014) and epilepsy with other etiologies (p=0.006) were associated with milder TBI severity. Posttraumatic epilepsy (p=0.002) and misinterpreted behavior (p=0.049) occurred with younger injury age. Psychopathology (p=0.020) and other neurologic events (p=0.002) occurred with older injury age. In evaluating possible PTE, clinicians should maintain a broad differential diagnosis to prevent misdiagnosis and inappropriate treatment.

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.

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

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

Patients diagnosed with nonepileptic seizures: their perspectives and experiences

The objective of this qualitative study was to examine how patients with nonepileptic seizures (NES) make sense of their illness experience in light of the many obstacles they may face when seeking treatment. We conducted semistructured interviews with five patients with NES to explore their illness perspectives and different modes of reasoning in regard to their illness and treatment experiences. The data were examined using thematic content analysis. The participants who implicitly incorporated epilepsy as an illness prototype demonstrated less effective treatment expectations and imposed greater life constraints on themselves than the participant who used anxiety attacks. The participants who defined an explanatory model with a psychosocial basis for illness onset were receptive and demanding of psychotherapeutic intervention. Emergent themes included accounts of adverse and positively perceived life events coinciding with illness onset, head injury, presence of caregivers during events, comorbid illness, and previously witnessing epilepsy in others.

Psychogenic non-epileptic seizures: a model of their pathogenic mechanism

Psychogenic non-epileptic seizures (PNES) consist of paroxystic events facilitated by a dysfunction in emotion processing. Models explaining the pathogenic mechanisms leading to these seizure-like episodes are limited. In this article, evidence that supports dysfunction at the level of arousal tolerance, cognitive-emotional information processing and volitional control is reviewed. A hypothetical pathophysiological mechanism is discussed based on functional neuroimaging evidence from PNES-related conditions and traits. This pathophysiological model suggests an alteration in the influence and connection of brain areas involved in emotion processing onto other brain areas responsible for sensorimotor and cognitive processes. Integrating this information, PNES are conceptualized as brief episodes facilitated by an unstable cognitive-emotional attention system. During the episodes, sensorimotor and cognitive processes are modified or not properly integrated, allowing the deployment of autonomous prewired behavioral tendencies. Finally, I elaborate on how therapeutic applications could be modified based on the proposed hypothetical model, potentially improving clinical outcomes.

Clinical features of psychogenic nonepileptic seizures: a study of 64 cases in southwest China

This article describes the clinical features of psychogenic nonepileptic seizures (PNES) in people in southwest China. Patients with a confirmed diagnosis of pure PNES by video/EEG monitoring were retrospectively reviewed. A total of 64 patients with PNES were included, 32 (50%) of whom were male. Twenty (31.3%) patients had previously been misdiagnosed and treated for epilepsy. Psychological trauma and head injuries were considered antecedent traumatic factors. A history of abuse was rare. The PNES cases were divided into three subtypes: psychogenic minor motor seizures, psychogenic major motor seizures, and unresponsive seizures. Age at onset was identified as a predictor of prognosis. The results of this study demonstrated a higher prevalence of PNES in males compared with previous studies. The semiology of PNES in China is similar to that in Western countries. Classification of semiology may be helpful in the differential diagnosis of PNES.

Heterogeneity in psychogenic nonepileptic seizures: understanding the role of psychiatric and neurological factors

Multiple psychiatric and neurological factors in patients with psychogenic nonepileptic seizures (PNES) highlight the heterogeneity of this population. Forty-four individuals with PNES were evaluated and divided into groups based on psychiatric and neurological morbidity. Groups were then examined to determine how they differed in terms of clinical presentation, semiology, level of dysfunction, severity of psychopathology, and specific psychiatric and neurological conditions. Individuals with neurological morbidity more frequently displayed sound production during their events. Factors relevant to treatment planning such as psychiatric conditions, psychopathology severity, and dysfunction level did not differ between the group with neurological morbidity and the group without significant psychiatric or neurological morbidity. Patients with significant psychiatric impairment had more frequent dissociative experiences, higher levels of dysfunction, and more frequent trauma-related diagnoses. Dysfunction was positively associated with depression severity and stress. Subgroups of patients with PNES based on their neurological and psychiatric morbidity manifest differences that might inform treatment.

Psychogenic nonepileptic seizures after head injury: a case report

Psychogenic nonepileptic seizures (PNESs) are diagnosed when disruptive changes in behaviour, thinking, or emotion resemble epileptic seizures (ESs), but no paroxysmal discharges are seen on electroencephalogram (EEG) and do not originate from another medical illness. The gold standard for PNES diagnosis is video electroencephalogram (Video-EEG). PNESs are defined by modern psychiatry as conversion and dissociative disorders but these disorders may coexist with many others psychiatric disorders, including depression, posttraumatic stress disorder, and personality disorders. It is well known that epileptic seizures are a frequent and well-studied complication of traumatic head injury (THI). However, THI may also generate psychic symptoms including PNES. In this paper we describe a patient who developed PNES after THI in a bus accident and received a diagnosis of refractory epilepsy for 24 years until she underwent Video-EEG.

"All that spikes is not fits", mistaking the woods for the trees: the interictal spikes--an "EEG chameleon" in the interface disorders of brain and mind: a critical review

Recent research into mammalian cortical neurophysiology, after 6 decades of Berger's seminal work on electroencephalography, has shifted the older concept of interictal epileptiform activity (IEA) away from that of a mere electrographic graphoelement of relevance to diagnostic implications in epilepsy. Instead, accumulating information has stressed the neuropsychological implications, cognitive and/or behavioral consequence of these electrophysiological events, which are the phenotypic expression of aberrations of actual biophysical cellular function. We feel that this review is germane to neuropsychiatry, however, a rather neglected area of research. There is a great scope for brain-behavior-EEG research in the future that can be complimented by other techniques of "neurobehavioral electrophysiology". This review does not address the "pearls, perils and pitfalls" in the use of EEG in epilepsy, but critically and systematically reappraises the published electroencephalographic correlates of human behavior. We reiterate that epileptiform and other paroxysmal EEG dysrhythmias unrelated to clinical seizures do have neuropsychological, cognitive and/or behavioral implications as seen in the various neuropsychiatric and neurobehavioral disorders discussed in this article. IEA and EEG dysrhythmias should neither be ignored as irrelevant nor automatically attributed to epilepsy. The relevance of these EEG aberrations in the disorders of the brain-mind interface extend beyond epilepsy, and may be an electrophysiological endophenotype of aberrant neuronal behavior indicative of underlying morpho-functional brain abnormalities. Magnetoencephalography (MEG), data fusion models (EEG-fMRI-BOLD), transcranial magnetic stimulation (TMS), evoked potentials (EP); intracranial electrophysiology, and EEG neurofeedback complemented by current functional neuroimaging techniques (fMRI and PET) would certainly help in further understanding the broader relationship between brain and behavior.

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.

How to avoid a misdiagnosis in patients presenting with transient loss of consciousness

Daily in the UK, frontline medical and paramedical staff are required to manage patients with "collapse ?cause". This universal colloquialism refers to patients who have had an abrupt loss of postural tone. Some of these patients would have had a "blackout" or a transient loss of consciousness (T-LOC). The three most important causes of T-LOC are syncope, epilepsy and psychogenic blackouts. Determining the correct cause is an important challenge; if the initial clinical diagnosis is wrong, investigations may be misdirected, and the final diagnosis and treatment incorrect. Syncope is much more common than epilepsy and may present with symptoms akin to the latter. This fact is not well appreciated and often leads to misdiagnosis. This article deals with the clinical features of the three main causes of blackouts, the value of investigations in arriving at a diagnosis and the problem of misdiagnosis. Pathways for managing patients presenting with blackouts are suggested.

Nonepileptic seizures treatment workshop summary

In May 2005, an international, interdisciplinary group of researchers gathered in Bethesda, MD, USA, for a workshop to discuss the development of treatments for patients with nonepileptic seizures (NES). Specific subgroup topics that were covered included: pediatric NES; presenting the diagnosis of NES, outcome measures for NES trials; classification of NES subtypes; and pharmacological treatment approaches and psychotherapies. The intent was to develop specific research strategies that can be expanded to involve a large segment of the epilepsy and psychiatric treatment communities. Various projects have resulted from the workshop, including the initial development of a prospective randomized clinical trial for NES.

Epilepsy in children

10.5 million children worldwide are estimated to have active epilepsy. Over the past 15 years, syndrome-oriented clinical and EEG diagnosis, and better aetiological diagnosis, especially supported by neuroimaging, has helped to clarify the diversity of epilepsy in children, and has improved management. Perinatal and postinfective encephalopathy, cortical dysplasia, and hippocampal sclerosis account for the most severe symptomatic epilepsies. Ion channel defects can underlie both benign age-related disorders and severe epileptic encephalopathies with a progressive disturbance in cerebral function. However, the reasons for age-related expression in children are not understood. Neither are the mechanisms whereby an epileptic encephalopathy originates. Several new drugs have been recently introduced but have provided limited therapeutic benefits. However, treatment and quality of life have improved because the syndrome-specific efficacy profile of drugs is better known, and there is heightened awareness that compounds with severe cognitive side-effects and heavy polytherapies should be avoided. Epilepsy surgery is an important option for a few well-selected individuals, but should be considered with great caution when there is no apparent underlying brain lesion.

Frequency of secondary conversion symptoms in children with psychogenic nonepileptic seizures

We retrospectively identified 22 patients (19 were girls) with psychogenic nonepileptic seizures (NES) studied with video EEG telemetry over a 24-month period. A history of other conversion symptoms was identified in 11 of 22 patients. Symptoms were frequently neurological in nature. A strong association with depression and history of abuse was noted in children with multiple conversion manifestations. These NES patients with secondary conversion symptoms may require more intensive psychological therapy and be at risk for long-term pathology.

The spectrum of nonepileptic events in children

Nonepileptic events (NEE) are common in children, and can be difficult to distinguish from epileptic events. Several strategies can assist in differentiation. The first is an age-based approach to the differential of commonly presenting EEs in neonates, infants, and adolescents. The next strategy is to identify key elements of the patient's history to narrow the possibilities, and third is a rational approach to ancillary testing. There are additional challenges to the diagnosis and evaluation of NEEs in patients with cognitive impairments or mental retardation (MR). Twenty to 25% of neurologically normal patients (34), and up to 60% of children with MR (35) referred for an evaluation of seizures, have NEE. In most instances, the clinical history leads to the diagnosis, and ancillary testing serves as confirmation. But in certain populations, neonates, children with concurrent epilepsy, children in whom pseudoseizures are suspected, and children with MR, early use of video-EEG telemetry is indicated to establish the diagnosis and avoid overtreatment with antiepileptic drugs (AEDs).

Psychiatric comorbidity and hostility in patients with psychogenic nonepileptic seizures compared with somatoform disorders and healthy controls

PURPOSE

To investigate the prevalence of psychiatric comorbidity and level of anxiety, depression, and aggression in patients with psychogenic nonepileptic seizures compared with those in patients with somatoform disorders and healthy controls.

METHODS

Twenty-three patients with psychogenic nonepileptic seizures (PNESs) and 23 age- and sex-matched patients with somatoform disorders (SDs) underwent a clinical and a semistructured psychiatric interview (MINI) and filled in the Hospital Anxiety and Depression scale (HAD) and the Aggression Questionnaire (AQ). Twenty-three sex- and age-matched controls without psychopathology also underwent a clinical interview and completed the HAD and AQ.

RESULTS

PNES reported more minor head injuries in the past than did the two comparison groups, and more unspecific EEG dysrhythmias were observed on EEG. Twenty-one PNES patients and 18 with SDs had comorbid psychiatric diagnoses. However, the mean number of comorbid psychiatric diagnoses was higher in the PNES group (1.9 +/- 0.3 compared with 1.5 +/- 0.5 in the SD group; p = 0.003). Ten PNES patients additionally had a somatoform pain disorder, and seven had an undifferentiated somatoform disorder. Both patient groups reported significantly higher levels of anxiety, depression, and anger than did the healthy controls, but the PNES patients had significantly higher level of hostility than both comparison groups.

CONCLUSIONS

Increased psychiatric comorbidity is known to be associated with poorer response to regular interventions, and hostility is associated with more hostile coping patterns, often interfering with treatment compliance. Thus the increased prevalence of soft neurologic signs and comorbid psychiatric disorders and increased hostility as well in the PNES group, emphasizes that assessment and treatment of patients with PNES referred to a tertiary center requires an integrated approach involving both neurologic and psychiatric resources.

Etiology, diagnosis, and treatment of nonepileptic seizures

Psychogenic nonepileptic seizures (NES) can be classified into five categories. This review focuses on NES associated with emotional conflict, by far the most common and important group. Etiology is speculative, but the background histories of these patients are often similar. The presence of a trauma history, depression, post-traumatic stress symptoms, and the use of dissociation plus cognitive dysfunction possibly point to an organic etiology. The presentation of NES in children and adults is discussed, along with the differential diagnosis. The diagnostic differential is lengthy, with epileptic seizures of frontal lobe origin presenting a unique challenge. Diagnostic procedures are reviewed with an emphasis on the utility of hypnosis with seizure induction. Presenting the diagnosis to the patient, the role of the neurologist, and the role of the mental health consultant are reviewed. Issues in the doctor-patient relationship are also addressed, as well as the overall prognosis.