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Reilly C, Jette N, Johnson EC, Kariuki SM, Meredith F, Wirrell E, Mula M, Smith ML, Walsh S, Fong CY, Wilmshurst JM, Kerr M, Valente K, Auvin S. Scoping review and expert-based consensus recommendations for assessment and management of psychogenic non-epileptic (functional) seizures (PNES) in children: A report from the Pediatric Psychiatric Issues Task Force of the International League Against Epilepsy. Epilepsia 2023; 64:3160-3195. [PMID: 37804168 DOI: 10.1111/epi.17768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/28/2023] [Accepted: 08/28/2023] [Indexed: 10/09/2023]
Abstract
Limited guidance exists regarding the assessment and management of psychogenic non-epileptic seizures (PNES) in children. Our aim was to develop consensus-based recommendations to fill this gap. The members of the International League Against Epilepsy (ILAE) Task Force on Pediatric Psychiatric Issues conducted a scoping review adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-SR) standards. This was supplemented with a Delphi process sent to pediatric PNES experts. Consensus was defined as ≥80% agreement. The systematic search identified 77 studies, the majority (55%) of which were retrospective (only one randomized clinical trial). The primary means of PNES identification was video electroencephalography (vEEG) in 84% of studies. Better outcome was associated with access to counseling/psychological intervention. Children with PNES have more frequent psychiatric disorders than controls. The Delphi resulted in 22 recommendations: Assessment-There was consensus on the importance of (1) taking a comprehensive developmental history; (2) obtaining a description of the events; (3) asking about potential stressors; (4) the need to use vEEG if available parent, self, and school reports and video recordings can contribute to a "probable" diagnosis; and (5) that invasive provocation techniques or deceit should not be employed. Management-There was consensus about the (1) need for a professional with expertise in epilepsy to remain involved for a period after PNES diagnosis; (2) provision of appropriate educational materials to the child and caregivers; and (3) that the decision on treatment modality for PNES in children should consider the child's age, cognitive ability, and family factors. Comorbidities-There was consensus that all children with PNES should be screened for mental health and neurodevelopmental difficulties. Recommendations to facilitate the assessment and management of PNES in children were developed. Future directions to fill knowledge gaps were proposed.
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Affiliation(s)
- Colin Reilly
- Research Department, Young Epilepsy, Lingfield, UK
- Department of Pediatrics, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Queen Silvia Children's Hospital, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Nathalie Jette
- Department of Neurology, Icahn School of Medicine at Mount Sinia, New York City, New York, USA
| | | | - Symon M Kariuki
- KEMRI-Wellcome Trust Research Trust Research Programme, Kilifi, Kenya
- Department of Psychiatry, University of Oxford, Oxford, UK
- Department of Public Health, Pwani University, Kilifi, Kenya
| | | | - Elaine Wirrell
- Divisions of Child and Adolescent Neurology and Epilepsy, Department of Neurology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marco Mula
- IMBE, St George's University and the Atkinson Morley Regional Neuroscience Centre, St George's University Hospital, London, UK
| | - Mary Lou Smith
- Department of Psychology, University of Toronto Mississauga and Neurosciences and Mental Health Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Samantha Walsh
- Levy Library, Icahn School of Medicine at Mount Sinai, New York City, New York, USA
| | - Choong Yi Fong
- Division of Paediatric Neurology, Department of Paediatrics, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Jo M Wilmshurst
- Department of Paediatric Neurology, Red Cross War Memorial Children's Hospital, Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Mike Kerr
- Institute of Psychological Medicine and Clinical Neurosciences Cardiff University, Cardiff, UK
| | - Kette Valente
- Clinical Neurophysiology Sector, University of São Paulo, Clinic Hospital (HCFMUSP), São Paulo, Brazil
| | - Stephane Auvin
- Université Paris Cité, INSERM NeuroDiderot, Paris, France
- Pediatric Neurology Department, APHP, Robert Debré University Hospital, CRMR epilepsies rares, EpiCare member, Paris, France
- Institut Universitaire de France (IUF), Paris, France
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Vasquez A, Hilliker DR, Wirrell EC. Pediatric psychogenic non-epileptic seizures: A retrospective observational cohort study at a quaternary center. Epilepsy Behav 2023; 146:109359. [PMID: 37499579 DOI: 10.1016/j.yebeh.2023.109359] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Revised: 07/11/2023] [Accepted: 07/13/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Psychogenic non-epileptic seizures (PNES) represent a common functional disorder in the pediatric population. We aimed to characterize pediatric PNES by describing their clinical characteristics, PNES semiologies, and healthcare pathway towards and after diagnosis. MATERIAL AND METHODS This was a retrospective, observational chart review of pediatric patients aged 6 to 18 years admitted between December 2020 and December 2021 for spell classification or suspected PNES. Psychogenic non-epileptic seizure diagnosis was made by the capture of a typical event on video electroencephalogram (vEEG). We used descriptive statistics to summarize demographic and clinical characteristics. RESULTS We included 26 patients (18 females, 69.2%) with a mean age (SD) of 13.9 (2.5) years. Pre-morbid neurologic and psychiatric conditions included: epilepsy (23.1%), migraine (46.2%), mild traumatic brain injury (26.9%), anxiety (57.7%), ADHD (34.6%), and depression (30.8%). Six patients (23.1%) had a prior diagnosis of PNES. 14 patients (53.8%) presented with convulsive, and 6 (23.1%) each with non-convulsive and mixed PNES. Patients were seen by a range of providers prior to diagnosis including ED providers (50%), neurologists (53.8%), pediatricians (34.6%), and psychology/psychiatry (11.5%). Emergency department evaluation occurred for 13 patients (50%) on 15 occasions, and six (23.1%) were admitted to the hospital. The median (p25-p75) time from PNES onset to presentation and diagnosis at our institution was 3.5 (1.5-6.2) and 4.1 (3-7) months, respectively. A total of 33 events from the 26 patients were captured on vEEG. The most frequent semiologies in our cohort were rhythmic motor (27.3%) followed by equal frequency (18.2%) of complex motor and dialeptic. Eighteen patients (69.2%) were followed after the PNES diagnosis, for a median (p25-p75) of 17.3 months (6.3-21) with variable outcome. CONCLUSION Pediatric PNES has female predominance and often presents with comorbid psychosocial stressors and psychiatric conditions. High clinical suspicion and early recognition are crucial to decrease healthcare utilization and establish timely diagnosis and treatment.
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Affiliation(s)
- Alejandra Vasquez
- Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States
| | - Daniel R Hilliker
- Division of Child and Adolescent Psychology and Psychiatry, Mayo Clinic, Rochester, MN, United States
| | - Elaine C Wirrell
- Division of Child and Adolescent Neurology, Department of Neurology, Mayo Clinic, Rochester, MN, United States.
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Kanemoto K, Tadokoro Y, Motooka H, Kawasaki J, Horinouchi T, Tsuji T, Fukuchi T, Tomohiro O. Prospective multicenter cohort study of possible psychogenic nonepileptic seizure cases-Results at 1-year follow-up examinations. Epilepsia Open 2023; 8:134-145. [PMID: 36509699 PMCID: PMC9978061 DOI: 10.1002/epi4.12683] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022] Open
Abstract
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.
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Affiliation(s)
| | | | | | | | - Toru Horinouchi
- Department of Psychiatry & Neurology, Hokkaido University, Sapporo, Japan
| | - Tomikimi Tsuji
- Department of Neuropsychiatry, Wakayama University, Wakayama, Japan
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Opp J, Job B. Dissoziative Anfälle frühzeitig erkennen. Monatsschr Kinderheilkd 2021. [DOI: 10.1007/s00112-021-01355-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
ZusammenfassungWenn dissoziative Anfälle, also psychogene, nichtepileptische Anfälle als epileptische Anfälle fehlgedeutet werden, führt dies zu frustraner medikamentöser Therapie und verzögert die Einleitung der erforderlichen psychotherapeutischen Maßnahmen. Folgende Anfallssymptome sollten an dissoziative Anfälle denken lassen: unrhythmisches, wildes Hin- und Herbewegen des Kopfes oder der Extremitäten, geschlossene Augen, lange Dauer und undulierender Verlauf. Ein unauffälliges Elektroenzephalogramm (EEG) spricht für dissoziative Anfälle, aber erst ein negativer EEG-Befund während eines Anfalls ist beweisend. Im Arztgespräch ist es entscheidend, dass die Betroffenen die Möglichkeit bekommen, frei zu schildern. Betroffene mit dissoziativen Anfällen zeigen dann Besonderheiten, die als Diagnosekriterien genutzt werden sollten: Sie fokussieren auf Begleitumstände und lassen in ihren Schilderungen den Moment des Bewusstseinsverlusts aus. Sie machen eher allgemeine Angaben und unterscheiden einzelne Anfälle kaum.
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Fredwall M, Terry D, Enciso L, Burch MM, Trott K, Albert DVF. Outcomes of children and adolescents 1 year after being seen in a multidisciplinary psychogenic nonepileptic seizures clinic. Epilepsia 2021; 62:2528-2538. [PMID: 34339046 DOI: 10.1111/epi.17031] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 07/19/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Psychogenic nonepileptic seizures (PNES) are paroxysmal events that may involve altered subjective experience and change in motor activity with a psychological cause. The aim of this work is to describe a population of pediatric patients with PNES and identify factors predictive of 12-month outcomes. METHODS We conducted a prospective observational study of children and adolescents referred to the multidisciplinary Nationwide Children's Hospital PNES clinic between November 2017 and July 2019. Information was collected from patients during clinic visits and semistructured follow-up phone calls. Descriptive statistics and Fisher exact test were used for analysis. RESULTS Of the 139 consecutive patients referred to the PNES clinic, 104 were seen in clinic and 63 answered 12-month follow-up calls. Patients with comorbid epilepsy had increased rates of participation at 12-month follow-up (p = .04). Complete remission was achieved by 32% (20/63) of patients at 12 months. Combined PNES remission and improvement was 89% (56/63) at 12 months. Patients and families who were linked with counseling at 1 month were more likely to achieve remission at 12 months (p = .005). Less than half (44%, 28/63) of patients reached at 12 months had their events documented on video-electroencephalogram (EEG) at diagnosis; however, those who did were not more likely to be accepting of the diagnosis at 12 months (p = 1.0), be linked with counseling at 12 months (p = .59), or be event-free at 12 months (p = .79). SIGNIFICANCE Remission occurred in one third of patients by 12 months; however, improvement in events was seen in 89%. Connection to counseling by 1 month was associated with increased remission rates at 12 months. Capturing events on video-EEG was not associated with increased acceptance or event freedom at 12 months. Diagnosis should be followed by strong encouragement to connect with counseling quickly to achieve a goal of increasing 12-month PNES remission rates.
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Affiliation(s)
- Megan Fredwall
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Debbie Terry
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Laurie Enciso
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Maggie Mary Burch
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Kristen Trott
- Department of Pediatrics, Division of Psychology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
| | - Dara V F Albert
- Department of Pediatrics, Division of Neurology, Nationwide Children's Hospital, Ohio State University, Columbus, Ohio, USA
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Psychogenic Nonepileptic Seizures in Children and Adolescents. Indian Pediatr 2021. [DOI: 10.1007/s13312-021-2167-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Bompaire F, Barthelemy S, Monin J, Quirins M, Marion L, Smith C, Boulogne S, Auxemery Y. PNES Epidemiology: What is known, what is new? EUROPEAN JOURNAL OF TRAUMA & DISSOCIATION 2021. [DOI: 10.1016/j.ejtd.2019.100136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Walther K, Volbers B, Erdmann L, Kurzbuch K, Lang JD, Mueller TM, Reindl C, Schwarz M, Schwab S, Hamer HM. Psychosocial long-term outcome in patients with psychogenic non-epileptic seizures. Seizure 2020; 83:187-192. [PMID: 33181426 DOI: 10.1016/j.seizure.2020.09.014] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/16/2020] [Accepted: 09/17/2020] [Indexed: 11/26/2022] Open
Abstract
PURPOSE To evaluate psychosocial long-term outcome in patients diagnosed with psychogenic nonepileptic seizures (PNES) and to predict outcome of PNES, economic status, and quality of life (QoL) at follow-up. METHODS Patients diagnosed with PNES in the video-EEG-monitoring unit at our Epilepsy center between 2002-2016 were contacted by phone 1-16 years after communicating the diagnosis. Patients underwent a structured interview asking for current PNES status, psychosocial situation (economic status, marital status, setting of living, driving), depression, and QoL. RESULTS Of 70 PNES patients without comorbid epilepsy (age: 41.1 ± 13.5 years; 74 % female, follow-up: 5.2 ± 4.2 years), 23 patients (33 %) reported to be free of PNES during the last 12 months. Patients with cessation of PNES were younger at PNES onset (p < .01) and diagnosis (p < .01) and had a higher education (p < .05). At follow-up, the proportion of economically active patients only increased in individuals with cessation of PNES (p < .001) while an increased number of patients with persisting PNES relied on governmental support (p < .001). Cessation of PNES was associated with better mood (p < .01) and QoL (p < .001). In multiple regression models, cessation of PNES was only predicted by younger age at onset, while good economic outcome was determined by younger age and good economic status at diagnosis and cessation of PNES at follow-up. Good QoL at follow-up was predicted by low depressive symptoms, freedom of PNES, and economic activity at follow-up. CONCLUSION Long-term outcome in patients with PNES remains to be poor and the majority of patients continue to have PNES. Cessation of PNES was associated with good economic outcome, mood, and QoL.
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Affiliation(s)
- Katrin Walther
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Bastian Volbers
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Laura Erdmann
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Katrin Kurzbuch
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Johannes D Lang
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Tamara M Mueller
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Caroline Reindl
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Schwarz
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Hajo M Hamer
- Epilepsy Center, Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
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Walther K, Volbers B, Erdmann L, Dogan Onugoren M, Gollwitzer S, Kasper BS, Kurzbuch K, Lang J, Schwab S, Schwarz M, Hamer HM. Psychological long‐term outcome in patients with psychogenic nonepileptic seizures. Epilepsia 2019; 60:669-678. [DOI: 10.1111/epi.14682] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 02/01/2019] [Accepted: 02/01/2019] [Indexed: 12/01/2022]
Affiliation(s)
- Katrin Walther
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
| | - Bastian Volbers
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
- Department of NeurologyInselspitalUniversity Hospital Bern Bern Switzerland
| | - Laura Erdmann
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
| | | | - Stephanie Gollwitzer
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
| | - Burkhard S. Kasper
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
| | - Katrin Kurzbuch
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
| | - Johannes Lang
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
| | - Stefan Schwab
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
| | - Michael Schwarz
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
| | - Hajo M. Hamer
- Department of NeurologyEpilepsy CenterUniversity Hospital Erlangen Erlangen Germany
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Nielsen ES, Wichaidit BT, Østergaard JR, Rask CU. Paediatricians' attitudes to and management of functional seizures in children. Eur J Paediatr Neurol 2018; 22:774-781. [PMID: 29871800 DOI: 10.1016/j.ejpn.2018.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 05/04/2018] [Accepted: 05/20/2018] [Indexed: 01/23/2023]
Abstract
OBJECTIVE To explore paediatricians' attitudes to and treatment practice for children with functional seizures (FS). METHODS In a nationwide survey, all 64 Danish neuro-paediatricians and social paediatricians were invited to complete a structured questionnaire encompassing FS-related issues that included beliefs and attitudes about aetiology and diagnostic assessment, current strategies for management, experienced need for clinical guidelines and better treatment options. RESULTS A total of 61 paediatricians (95%) participated in the study. Nearly half (46%) had seen more than 30 children with FS during their career. Most (65%) believed in a primarily psychogenic aetiology. More than half (57%) stated that they could make the diagnosis by solely observing a seizure, and 18% indicated the children faked their symptoms. The paediatricians' responses to these issues did not significantly vary according to their level of clinical experience. Furthermore, the majority (78%) expressed a need for clinical guidelines, and only 13% rated existing treatment options as sufficient. Collaborative care between different specialties or management in a child and adolescent mental health services (CAMHS) setting was seen as the best model for treatment. However, only 23% reported often referring these children to CAMHS after making the diagnosis. CONCLUSION The findings suggest that introduction of clinical guidelines in this area is highly needed. Such guidelines could promote more formal training of paediatricians in understanding and assessing FS and increased collaboration between paediatrics and CAMHS regarding care for children with this challenging and potentially costly and disabling disorder.
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Affiliation(s)
| | - Bianca Taaning Wichaidit
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark
| | | | - Charlotte Ulrikka Rask
- The Research Clinic for Functional Disorders and Psychosomatics, Aarhus University Hospital, Denmark; Child and Adolescent Psychiatric Centre, Aarhus University Hospital, Risskov, Denmark
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Heyer GL, Pabst LM, Kaucic BN, Coley TA. Early outcomes in youth with psychogenic nonsyncopal collapse. Neurology 2018; 91:e850-e858. [DOI: 10.1212/wnl.0000000000006098] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/25/2018] [Indexed: 12/17/2022] Open
Abstract
ObjectiveTo evaluate several early outcome measures following diagnosis of psychogenic nonsyncopal collapse (PNSC).MethodsOver 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.ResultsEighty-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.ConclusionsThe 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.
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Luthy SK, Moss AF, Torok MR, McLeod L, Wilson KM. Characteristics of Children Hospitalized for Psychogenic Nonepileptic Seizures Due to Conversion Disorder Versus Epilepsy. Hosp Pediatr 2018; 8:321-329. [PMID: 29739840 DOI: 10.1542/hpeds.2017-0103] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
OBJECTIVES Psychogenic nonepileptic seizures (PNES) are a manifestation of conversion disorder among children but can be difficult to distinguish from epilepsy. We sought to identify characteristics that differentiate children with PNES from those with epilepsy. METHODS We conducted a retrospective cohort study of children admitted with epilepsy or PNES to 45 children's hospitals from 2004 to 2014. Children with PNES (n = 399) versus those with epilepsy (n = 13 241) were compared on demographic and clinical characteristics, testing, treatment, and health care use. Hierarchical multivariable logistic regression was used to identify characteristics associated with PNES diagnosis. RESULTS Children with PNES were more likely to be female (adjusted odds ratio [aOR] 2.3; 95% confidence interval [CI] 1.8-3.0), older (aOR 3.8; 95% CI 2.7-5.3 for 14-16 years old), African American (aOR 2.0; 95% CI 1.5-2.7), and have diagnosis codes for psychiatric disorders (aOR 7.1; 95% CI 5.6-9.1) and pain (aOR 2.6; 95% CI 1.9-3.4). They were also more likely to be admitted in the fall (aOR 2.0; 95% CI 1.4-2.8) or spring (aOR 1.9; 95% CI 1.4-2.6) versus summer. Total adjusted hospitalization costs were greater for children with epilepsy ($4724, 95% CI $4413-$5057 vs $5326, 95% CI $5259-$5393; P = .001); length of stay was similar. CONCLUSIONS Demographic and clinical characteristics differed among children with PNES versus those with epilepsy, including significantly increased odds of psychiatric and pain diagnoses among children with PNES. To better inform treatment and prognostication for children with PNES, research is needed to understand reasons for these differences, seasonal admission patterns, and the relationship between PNES and other psychiatric disorders.
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Affiliation(s)
- Sarah K Luthy
- Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, Ohio;
- Division of Hospital Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Angela F Moss
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, Colorado
| | - Michelle R Torok
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, Colorado
| | - Lisa McLeod
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, School of Medicine, University of Colorado, Aurora, Colorado
- Section of Pediatric Hospital Medicine, Children's Hospital Colorado, Aurora, Colorado; and
| | - Karen M Wilson
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, New York
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Sheth SA, Chandra NC, Mehta RY. Temporal Lobe Seizures Presenting as Abrupt Clinging Behavior in a Child. Indian J Psychol Med 2017; 39:527-530. [PMID: 28852255 PMCID: PMC5560009 DOI: 10.4103/0253-7176.211761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
True and psychogenic nonepileptic seizures (PNES) go hand in hand. One colors the picture of other. Although it is thought that children carry lower risk for PNES than adults, this may represent the under-diagnosis of this condition in childhood due to few studies on this specific topic. Again, true seizure can be misdiagnosed by dramatic and varied manifestations appearing as psychological phenomena. We report a case of a 9-year-old boy presenting with sudden onset, short lasting, off and on different "melodramatic" episodic behavioral problems with La-Belle' indifference without loss of consciousness, appearing to be of psychogenic origin but finally ended with a diagnosis of temporal lobe epilepsy and responded dramatically with antiepileptics. The goal of this case report is to alert the reader to be cautious about rarer presentations of epilepsy and see each case holistically which may be misguided as PNES.
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Affiliation(s)
- Shabina A Sheth
- Department of Psychiatry, Government Medical College and New Civil Hospital, Surat, Gujarat, India
| | - Nilanjan C Chandra
- Department of Psychiatry, Government Medical College and New Civil Hospital, Surat, Gujarat, India
| | - Ritambhara Y Mehta
- Department of Psychiatry, Government Medical College and New Civil Hospital, Surat, Gujarat, India
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Kanemoto K, LaFrance WC, Duncan R, Gigineishvili D, Park S, Tadokoro Y, Ikeda H, Paul R, Zhou D, Taniguchi G, Kerr M, Oshima T, Jin K, Reuber M. PNES around the world: Where we are now and how we can close the diagnosis and treatment gaps-an ILAE PNES Task Force report. Epilepsia Open 2017; 2:307-316. [PMID: 29588959 PMCID: PMC5862115 DOI: 10.1002/epi4.12060] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2017] [Indexed: 02/05/2023] Open
Abstract
An international consensus clinical practice statement issued in 2011 ranked psychogenic nonepileptic seizures (PNES) among the top three neuropsychiatric problems. An ILAE PNES Task Force was founded and initially charged with summarizing the current state of the art in terms of diagnosis and treatment, resulting in two publications. The first described different levels of diagnostic certainty. The second summarized current knowledge of management approaches. The present paper summarizes an international workshop of the ILAE PNES Task Force that focused on the current understanding and management of PNES around the world. We initially provide a knowledge update about the etiology, epidemiology, and prognosis of PNES-in adults and in special patient groups, such as children, older adults, and those with intellectual disability. We then explore clinical management pathways and obstacles to optimal care for this disorder around the world by focusing on a number of countries with different cultural backgrounds and at very different stages of social and economic development (United Kingdom, U.S.A., Zambia, Georgia, China, and Japan). Although evidence-based methods for the diagnosis and treatment of PNES have now been described, and much is known about the biopsychosocial underpinnings of this disorder, this paper describes gaps in care (not only in less developed countries) that result in patients with PNES not having adequate access to healthcare provisions. A range of challenges requiring solutions tailored to different healthcare systems emerges. Continued attention to PNES by the ILAE and other national and international neurologic, psychiatric, and health organizations, along with ongoing international collaboration, should ensure that patients with PNES do not lose out as healthcare services evolve around the world.
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Affiliation(s)
- Kousuke Kanemoto
- Department of NeuropsychiatryAichi Medical UniversityNagakuteJapan
| | - W. Curt LaFrance
- Rhode Island HospitalBrown UniversityProvidenceRhode IslandU.S.A.
| | | | - David Gigineishvili
- Department of Neurology & NeurosurgerySarajishvili Institute of NeurologyTbilisi State UniversityTbilisiGeorgia
| | - Sung‐Pa Park
- Department of NeurologyKyungpook National University School of MedicineDaeguKorea
| | - Yukari Tadokoro
- Department of NeuropsychiatryAichi Medical UniversityNagakuteJapan
| | - Hiroko Ikeda
- Department of PediatricsEpilepsy CenterNHO Shizuoka Institute of Epilepsy and Neurological DisordersShizuokaJapan
| | - Ravi Paul
- Department of PsychiatrySchool of MedicineUniversity of ZambiaLusakaZambia
| | - Dong Zhou
- Department of NeurologyWest China HospitalSichuan UniversityChengduChina
| | - Go Taniguchi
- Department of Neuropsychiatrythe University of TokyoTokyoJapan
| | - Mike Kerr
- Learning Disability PsychiatryCardiff UniversityCardiffUnited Kingdom
| | - Tomohiro Oshima
- Department of NeuropsychiatryAichi Medical UniversityNagakuteJapan
| | - Kazutaka Jin
- Tohoku Daigaku Daigakuin Igakukei Kenkyuka IgakubuSendaiMiyagiJapan
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Heyer GL, Harvey RA, Islam MP. Comparison of Specific Fainting Characteristics Between Youth With Tilt-Induced Psychogenic Nonsyncopal Collapse Versus Reflex Syncope. Am J Cardiol 2017; 119:1116-1120. [PMID: 28236458 DOI: 10.1016/j.amjcard.2016.12.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Revised: 12/15/2016] [Accepted: 12/15/2016] [Indexed: 10/20/2022]
Abstract
Little is known about the predictive features of psychogenic nonsyncopal collapse (PNSC). The aim of the present study was to compare the self-reported fainting characteristics between young patients who were ultimately diagnosed with PNSC with those ultimately diagnosed with neurally mediated syncope and to determine which features were predictive of either diagnosis. A prospective study was conducted of sequential patients referred for fainting. All study data were obtained before testing or diagnosis. Several fainting characteristics were compared between cohorts including numbers of lifetime fainting episodes, fainting frequency the week before evaluation, fainting duration, numbers of fainting spells in a single day, presence of presyncope, types of prodromal symptoms, tearfulness with fainting, and the numbers of emergency department visits and hospital admission for fainting. During the study period, 52 patients were diagnosed with PNSC, producing a diagnostic rate of 18.9%. In univariate analyses, multiple features differed between patients with PNSC and those with syncope. After controlling for age and gender in a multivariate analysis, each of the following predicted PNSC: ≥20 lifetime fainting spells (p = 0.005), ≥2 fainting spells in a single day (p = 0.03), self-reported loss of consciousness ≥2 minutes (p = 0.01), and tearfulness associated with fainting (p = 0.022). Two or more typical prodromal symptoms (p = 0.004) predicted syncope. In conclusion, several characteristics related to fainting have predictive value in distinguishing PNSC from syncope, particularly among youth. Assessing these clinical features can help to inform appropriate testing and accurate diagnosis among patients who faint.
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Risk Factors for Diagnostic Delay in Psychogenic Nonepileptic Seizures Among Children and Adolescents. Pediatr Neurol 2017; 67:71-77. [PMID: 27955838 DOI: 10.1016/j.pediatrneurol.2016.10.021] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2016] [Revised: 10/27/2016] [Accepted: 10/31/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND This study aims to analyze a series of pediatric patients with psychogenic nonepileptic seizures (PNES) to establish the diagnostic gap and possible risk factors for the delayed diagnosis in this age group. METHODS We evaluated all children with PNES documented by video electroencephalography. None had a previous diagnosis of PNES. In total, we included 53 children (interquartile range: seven to 17 years; mean age 12.81 years [S.D. 3.15]; 60.4% girls) who underwent a protocol consisting of neurological and psychiatric interviews. RESULTS The average time between seizure onset and referral was 17.76 months (interquartile range: 0.5 to 48 months; S.D. ± 12.62). Earlier age of onset correlated with a later diagnosis (P < 0.001). The late referral group also presented with a history of psychological abuse (P = 0.018). CONCLUSION Youth with PNES represent a diagnostic challenge. Identification of children at risk might lead to earlier diagnosis of PNES.
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Saal DP, Overdijk MJ, Thijs RD, van Vliet IM, van Dijk JG. Long-term follow-up of psychogenic pseudosyncope. Neurology 2016; 87:2214-2219. [PMID: 27784771 DOI: 10.1212/wnl.0000000000003361] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 08/15/2016] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine the outcome of patients with psychogenic pseudosyncope (PPS) after communication of the diagnosis. METHODS This was a retrospective cohort study of patients with PPS referred in 2007 to 2015 to a tertiary referral center for syncope. We reviewed patient records and studied attack frequency, factors affecting attack frequency, health care use, and quality of life using a questionnaire. We explored influences on attack freedom and attack frequency in the 6 months before follow-up for age, sex, education level, duration until diagnosis, probability of diagnosis, additional syncope, and acceptance of diagnosis. RESULTS Forty-seven of 57 patients with PPS could be traced, of whom 35 (74%) participated. Twelve (34%) were attack-free for at least 6 months. The median time from diagnosis to follow-up was 50 months (range 6-103 months). Communicating and explaining the diagnosis resulted in immediate reduction of attack frequency (p = 0.007) from the month before diagnosis (median one attack, range 0-156) to the month after (median one attack, range 0-16). In the 6 months before follow-up, the number of admissions decreased from 19 of 35 to 0 of 35 (p = 0.002). The use of somatic and mental health care shifted toward the latter (p < 0.0001). Quality of life at follow-up (Short Form Health Survey 36) showed lower scores for 7 of 8 domains compared to matched Dutch control values; quality of life was not influenced by attack freedom. CONCLUSIONS After communication of the diagnosis in PPS, attack frequency decreased and health care use shifted toward mental care. Low quality of life underlines that PPS is a serious condition.
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Affiliation(s)
- Dirk P Saal
- From the Departments of Neurology and Clinical Neurophysiology (D.P.S., J.G.v.D.) and Psychiatry (I.M.v.V.), Leiden University Medical Center; Department of Neurology (M.J.O.), Medical Center Haaglanden, The Hague; and Stichting Epilepsie Instellingen Nederland (R.D.T.), Heemstede, the Netherlands
| | - M Jolein Overdijk
- From the Departments of Neurology and Clinical Neurophysiology (D.P.S., J.G.v.D.) and Psychiatry (I.M.v.V.), Leiden University Medical Center; Department of Neurology (M.J.O.), Medical Center Haaglanden, The Hague; and Stichting Epilepsie Instellingen Nederland (R.D.T.), Heemstede, the Netherlands
| | - Roland D Thijs
- From the Departments of Neurology and Clinical Neurophysiology (D.P.S., J.G.v.D.) and Psychiatry (I.M.v.V.), Leiden University Medical Center; Department of Neurology (M.J.O.), Medical Center Haaglanden, The Hague; and Stichting Epilepsie Instellingen Nederland (R.D.T.), Heemstede, the Netherlands
| | - Irene M van Vliet
- From the Departments of Neurology and Clinical Neurophysiology (D.P.S., J.G.v.D.) and Psychiatry (I.M.v.V.), Leiden University Medical Center; Department of Neurology (M.J.O.), Medical Center Haaglanden, The Hague; and Stichting Epilepsie Instellingen Nederland (R.D.T.), Heemstede, the Netherlands
| | - J Gert van Dijk
- From the Departments of Neurology and Clinical Neurophysiology (D.P.S., J.G.v.D.) and Psychiatry (I.M.v.V.), Leiden University Medical Center; Department of Neurology (M.J.O.), Medical Center Haaglanden, The Hague; and Stichting Epilepsie Instellingen Nederland (R.D.T.), Heemstede, the Netherlands.
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Yadav A, Agarwal R, Park J. Outcome of psychogenic nonepileptic seizures (PNES) in children: A 2-year follow-up study. Epilepsy Behav 2015; 53:168-73. [PMID: 26580213 DOI: 10.1016/j.yebeh.2015.10.017] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Revised: 10/12/2015] [Accepted: 10/16/2015] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Ashok Yadav
- Epilepsy Section, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, OH, USA.
| | - Rajkumar Agarwal
- Epilepsy Section, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, OH, USA.
| | - Jun Park
- Epilepsy Section, Rainbow Babies and Children's Hospital, University Hospitals Case Medical Center, Cleveland, OH, USA.
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Brough JL, Moghaddam NG, Gresswell DM, Dawson DL. The impact of receiving a diagnosis of Non-Epileptic Attack Disorder (NEAD): A systematic review. J Psychosom Res 2015; 79:420-7. [PMID: 26526318 DOI: 10.1016/j.jpsychores.2015.09.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Revised: 09/15/2015] [Accepted: 09/19/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Clinicians have reported observations of the immediate cessation of non-epileptic attacks after the diagnosis of NEAD is presented. OBJECTIVE The purpose of this systematic review was to examine the impact of receiving a diagnosis of NEAD. SEARCH STRATEGY A literature search across the databases Medline, PsycINFO, EMBASE, and CINAHL, and additional hand searching, identified six original studies meeting criteria for the review. SELECTION CRITERIA Included studies were original peer-reviewed articles investigating the impact of receiving a diagnosis of NEAD on adult populations with at least one outcome measured pre- and post-diagnosis. ANALYSIS The studies were assessed for methodological quality, including biases. This assessment was developed to include criteria specific to research regarding NEAD and diagnosis. RESULTS Six identified studies, with a total of 153 NEAD participants, examined the impact of receiving a diagnosis on seizure frequency. Two of the six also examined the impact on health-related quality of life. The findings were inconsistent, with approximately half the participants experiencing seizure reduction or cessation post-diagnosis. Diagnosis appeared to have no significant impact on health-related quality of life. The overall evidence lacked quality, particularly in study design and statistical rigour. CONCLUSIONS Mixed results and a lack of high quality evidence were found. Concerns are considered regarding the appropriateness of seizure frequency as the primary outcome measure and the use of epilepsy control groups. Indications for future research include: measuring more meaningful outcomes, using larger samples and power calculations, and ensuring consistent and standard methods for communicating the diagnosis and recording outcomes.
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Affiliation(s)
- Jenna L Brough
- Department of Doctoral Clinical Psychology, University of Lincoln, Bridge House, Brayford Pool, Lincoln LN7 6TS, UK.
| | - Nima G Moghaddam
- Department of Doctoral Clinical Psychology, University of Lincoln, Bridge House, Brayford Pool, Lincoln LN7 6TS, UK
| | - David M Gresswell
- Department of Doctoral Clinical Psychology, University of Lincoln, Bridge House, Brayford Pool, Lincoln LN7 6TS, UK
| | - David L Dawson
- Department of Doctoral Clinical Psychology, University of Lincoln, Bridge House, Brayford Pool, Lincoln LN7 6TS, UK
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Psychogenic Paroxysmal Nonepileptic Events in Children: A Review. Pediatr Neurol 2015; 53:13-22. [PMID: 25987362 DOI: 10.1016/j.pediatrneurol.2015.03.017] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Revised: 10/28/2014] [Accepted: 03/17/2015] [Indexed: 11/22/2022]
Abstract
BACKGROUND Paroxysmal nonepileptic events are common in children. Events with a psychological basis, historically referred to as pseudoseizures, are a large subset of paroxysmal nonepileptic events. METHODS A review of the relevant pediatric and adult literature was performed. RESULTS It was found that these events have many semioloigc features similar to epileptic events and can be challenging to correctly identify. The use of a detailed history in combination with video encephalography and knowledge of psychogenic paroxysmal nonepileptic events will facilitate making the correct diagnosis. Paroxysmal nonepileptic events are important to identify as comorbid disorders such as depression, anxiety disorder, family discord, and school issues are frequent. In addition, prior sexual, emotional, and/or physical abuse may be present. CONCLUSIONS Pediatric patients with paroxysmal nonepileptic events need to be recognized in order to avoid unnecessary antiepileptic drugs and emergency department or hospital visits and to facilitate appropriate psychological intervention to address the underlying etiologies. This review will focus on evaluation and identification of paroxysmal nonepileptic events, in addition to reviewing the various comorbidities, effective treatments, and outcomes for pediatric patients. The key differences between pediatric and adult patients with paroxysmal nonepileptic events are addressed.
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Yayla S, Bakım B, Tankaya O, Ozer OA, Karamustafalioglu O, Ertekin H, Tekin A. Psychiatric comorbidity in patients with conversion disorder and prevalence of dissociative symptoms. J Trauma Dissociation 2015; 16:29-38. [PMID: 25365395 DOI: 10.1080/15299732.2014.938214] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The 1st objective of the current study was to investigate the frequency and types of dissociative symptoms in patients with conversion disorder (CD). The 2nd objective of the current study was to determine psychiatric comorbidity in patients with and without dissociative symptoms. A total of 54 consecutive consenting patients primarily diagnosed with CD according to Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, criteria who were admitted to the psychiatric emergency outpatient clinic of Sisli Etfal Research and Teaching Hospital (Istanbul, Turkey) were included in the study. The Structured Clinical Interview for DSM-IV Axis I Disorders, Structured Interview for DSM-IV Dissociative Disorders, and Dissociative Experiences Scale were administered. Study groups consisted of 20 patients with a dissociative disorder and 34 patients without a diagnosis of any dissociative disorder. A total of 37% of patients with CD had any dissociative diagnosis. The prevalence of dissociative disorders was as follows: 18.5% dissociative disorder not otherwise specified, 14.8% dissociative amnesia, and 3.7% depersonalization disorder. Significant differences were found between the study groups with respect to comorbidity of bipolar disorder, past hypomania, and current and past posttraumatic stress disorder (ps = .001, .028, .015, and .028, respectively). Overall comorbidity of bipolar disorder was 27.8%. Psychiatric comorbidity was higher and age at onset was earlier among dissociative patients compared to patients without dissociative symptoms. The increased psychiatric comorbidity and early onset of conversion disorder found in patients with dissociative symptoms suggest that these patients may have had a more severe form of conversion disorder.
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Affiliation(s)
- Sinan Yayla
- a Department of Psychiatry , Kastamonu State Hospital , Kastamonu , Turkey
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Dhiman V, Sinha S, Rawat VS, Vijaysagar KJ, Thippeswamy H, Srinath S, Chaturvedi SK, Satishchandra P. Children with psychogenic non-epileptic seizures (PNES): a detailed semiologic analysis and modified new classification. Brain Dev 2014; 36:287-93. [PMID: 23756292 DOI: 10.1016/j.braindev.2013.05.002] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2013] [Revised: 05/05/2013] [Accepted: 05/08/2013] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Vikas Dhiman
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Sanjib Sinha
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India.
| | - Vikram Singh Rawat
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Kommu John Vijaysagar
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Harish Thippeswamy
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Shobha Srinath
- Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Santosh Kumar Chaturvedi
- Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
| | - Parthasarthy Satishchandra
- Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India
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Reilly C, Menlove L, Fenton V, Das KB. Psychogenic nonepileptic seizures in children: A review. Epilepsia 2013; 54:1715-24. [DOI: 10.1111/epi.12336] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/01/2013] [Indexed: 11/28/2022]
Affiliation(s)
- Colin Reilly
- Research Department; Young Epilepsy; Surrey; United Kingdom
| | - Leanne Menlove
- Research Department; Young Epilepsy; Surrey; United Kingdom
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Abstract
PURPOSE OF REVIEW This article will review the important steps in making an accurate diagnosis of psychogenic nonepileptic events or episodes (PNEE), and recent developments in diagnosis and treatment. RECENT FINDINGS Several clues can be obtained from the history to help the clinician suspect the diagnosis of PNEE. While none of these clues are diagnostic on their own, each is valuable, and there are often multiple clues in a given patient. Clinical clues have limitations, and once PNEE is suspected, video-EEG monitoring remains the gold standard and the only way to make a definite diagnosis of PNEE. Like most tests, video EEG has its limitations, but in most cases the diagnosis can be made and is not difficult. Regarding treatment, growing evidence exists that psychotherapy, especially cognitive behavior therapy, is effective, and a recent finding is that pharmacotherapy may have a role. SUMMARY The diagnosis of PNEE can be made reliably, but the management of PNEE remains problematic, in large part because of the insufficient involvement of mental health professionals.
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Affiliation(s)
- Selim R Benbadis
- University of South Florida and Tampa General Hospital, 2 Tampa General Circle, Floor 6, Tampa, Florida 33606, USA.
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Morgan LA, Dvorchik I, Williams KL, Jarrar RG, Buchhalter JR. Parental ranking of terms describing nonepileptic events. Pediatr Neurol 2013; 48:378-82. [PMID: 23583055 DOI: 10.1016/j.pediatrneurol.2012.12.029] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Accepted: 12/31/2012] [Indexed: 10/27/2022]
Abstract
Paroxysmal nonepileptic events of psychogenic etiology in children and adolescents are common. Patients and their parents are often confused by the terminology used to describe these events. This can lead to frustration and may result in the failure to obtain the necessary nonpharmacologic treatment. Various terms are used to describe such events, some of which might be considered offensive to some individuals. Surveys from 146 parents or guardians of patients identified from a general pediatric clinic, a general neurology clinic, and a pediatric epilepsy monitoring unit were completed with the aim of determining which words and phrases were least offensive. It was determined that nonepileptic events, functional seizures, and nonepileptic attack disorder were the least offensive labels; whereas "it is all in his or her head," hysterical seizures, and psychogenic seizures were the most offensive terms. This is the only study of its type in the pediatric population. Although each child and family requires individualized communication, we hope that this article will provide useful information to guide the practicing pediatric neurologist in informing families that their children are having events of nonepileptic etiology.
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Affiliation(s)
- Lindsey A Morgan
- Department of Pediatrics, Phoenix Children's Hospital, Phoenix, Arizona, USA
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Matsumoto JH, Caplan R, McArthur DL, Forgey MJ, Yudovin S, Giza CC. Prevalence of epileptic and nonepileptic events after pediatric traumatic brain injury. Epilepsy Behav 2013; 27:233-7. [PMID: 23480860 DOI: 10.1016/j.yebeh.2013.01.024] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2012] [Revised: 01/23/2013] [Accepted: 01/29/2013] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Joyce H Matsumoto
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at UCLA, USA.
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Bodde NMG, van der Kruijs SJM, Ijff DM, Lazeron RHC, Vonck KEJ, Boon PAJM, Aldenkamp AP. Subgroup classification in patients with psychogenic non-epileptic seizures. Epilepsy Behav 2013. [PMID: 23200772 DOI: 10.1016/j.yebeh.2012.10.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
INTRODUCTION In this open non-controlled clinical cohort study, the applicability of a theoretical model for the diagnosis of psychogenic non-epileptic seizures (PNES) was studied in order to define a general psychological profile and to specify possible subgroups. METHODS Forty PNES patients were assessed with a PNES "test battery" consisting of eleven psychological instruments, e.g., a trauma checklist, the global cognitive level, mental flexibility, speed of information processing, personality factors, dissociation, daily hassles and stress and coping factors. RESULTS The total PNES group was characterized by multiple trauma, personality vulnerability (in a lesser extent, neuropsychological vulnerabilities), no increased dissociation, many complaints about daily hassles that may trigger seizures and negative coping strategies that may contribute to prolongation of the seizures. Using factor analysis, specific subgroups were revealed: a 'psychotrauma subgroup', a 'high vulnerability somatizing subgroup' (with high and low cognitive levels) and a 'high vulnerability sensitive personality problem subgroup'. CONCLUSION Using a theoretical model in PNES diagnosis, PNES seem to be a symptom of distinct underlying etiological factors with different accents in the model. Hence, describing a general profile seems to conceal specific subgroups with subsequent treatment implications. This study identified three factors, representing two dimensions of the model, that are essential for subgroup classification: psychological etiology (psychotrauma or not), vulnerability, e.g., the somatization tendency, and sensitive personality problems/characteristics ('novelty seeking'). For treatment, this means that interventions could be tailored to the main underlying etiological problem. Also, further research could focus on differentiating subgroups with subsequent treatment indications and possible different prognoses.
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Affiliation(s)
- N M G Bodde
- Department of Behavioral Research and Psychological Services, Epilepsy Center Kempenhaeghe, Heeze, The Netherlands.
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Abstract
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.
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Affiliation(s)
- Anne Lortie
- Department of Pediatrics, Université de Montréal and CHU Sainte Justine, Montreal, Canada.
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Spitz MA, Vercueil L, Dubois-Teklali F. Pseudostatus epilepticus : une complication grave des crises non épileptiques psychogènes (CNEP) chez l’enfant. Arch Pediatr 2012; 19:47-50. [DOI: 10.1016/j.arcped.2011.10.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2011] [Revised: 06/17/2011] [Accepted: 10/07/2011] [Indexed: 10/15/2022]
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Patients with psychogenic non-epileptic seizures referred to a tertiary epilepsy centre: patient characteristics in relation to diagnostic delay. Clin Neurol Neurosurg 2011; 114:217-22. [PMID: 22071205 DOI: 10.1016/j.clineuro.2011.10.019] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Accepted: 10/11/2011] [Indexed: 11/22/2022]
Abstract
OBJECTIVE This clinical study examines patient and seizure characteristics of patients with psychogenic non-epileptic seizures (PNES) in a tertiary epilepsy centre. The main focus was whether a new subgroup of PNES patients emerged with a relatively short referral time and possible specific characteristics. METHODS All PNES patients referred to a specialist program in our centre between mid 2007 and mid 2009 were consecutively included. This yielded a study cohort of 90 patients. RESULTS The majority of the patients have a patient history with many medical symptoms and they were or had been in treatment by a medical specialist. Furthermore diffuse psychological/psychiatric symptoms and subsequent treatments are also remarkably common, in general without a clear psychological diagnosis. The average time between seizure onset and referral to an epilepsy centre is remarkably low (4.29 years). About 50% of the patients were referred within 2 years of seizure onset. This 'active high speed referral group' had significantly more previous psychological complaints, significantly more previous psychological/psychiatric treatments and a trend towards more previous medical investigations. CONCLUSION There seems to be a new subgroup of PNES patients with a short referral time, characterized by a more active attitude towards examination of the symptoms in combination with an active attitude to apply for treatment. However, the PNES cohort as a whole is characterized by having somatoform symptoms based on a process of somatization.
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Magaudda A, Gugliotta SC, Tallarico R, Buccheri T, Alfa R, Laganà A. Identification of three distinct groups of patients with both epilepsy and psychogenic nonepileptic seizures. Epilepsy Behav 2011; 22:318-23. [PMID: 21840769 DOI: 10.1016/j.yebeh.2011.07.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2011] [Revised: 06/27/2011] [Accepted: 07/05/2011] [Indexed: 10/15/2022]
Abstract
Psychogenic nonepileptic seizures (PNES) can be observed in patients with or without epilepsy (mixed and pure PNES). Patients with mixed PNES are usually considered to be a homogeneous group characterized by the coexistent epilepsy. Our study found that patients with mixed PNES were not homogeneous, but could be divided into three groups based on epilepsy type, mental level, comorbid psychiatric disorders, and history of traumatic experiences. Group 1 patients have pharmacoresistant epilepsy, normal cognition, and comorbid anxiety and/or depressive disorders. Here, PNES etiology is the epilepsy-related problems. In group 2 patients, the epilepsy is associated with mental retardation and dependent personality traits. PNES etiology is represented by the reduction or cessation of seizures. The PNES allow patients to continue receiving attention from caregivers. Group 3 patients have epilepsy, normal cognition, comorbid cluster B personality disorders and anxiety disorders, and psychic trauma. Here, PNES etiology is not related to the epilepsy, but to the psychic trauma.
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Affiliation(s)
- A Magaudda
- Epilepsy Center, Neuroscience Department, University of Messina, Messina, Italy.
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Abstract
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.
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Lund C, Haraldsen I, Lossius MI, Bjørnaes H, Lossius R, Nakken KO. [Psychogenic non-epileptic seizures]. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2009; 129:2348-51. [PMID: 19935934 DOI: 10.4045/tidsskr.09.0300] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Abstract
BACKGROUND Psychogenic non-epileptic seizure is the term used for epilepsy-like seizures assumed to have psychological causes. Many patients with such seizures are misdiagnosed with epilepsy, and are consequently treated with antiepileptic drugs for many years. Assessment of a thorough medical history and ictal EEG-recordings will lead to the right diagnosis in most cases. The article provides an overview of this condition, which often represents large diagnostic and therapeutic challenges and is the most frequent differential diagnosis in epilepsy. MATERIAL AND METHODS The article is based on literature identified through a non-systematic search in PubMed up to January 2009. RESULTS Much literature is available in the field. 10-20 % of those referred to epilepsy centers because of therapy-resistant epilepsy, have psychogenic non-epileptic seizures. 70-80 % of these patients are women. The attacks may resemble all types of epileptic seizures, from absence-like episodes to tonic-clonic-like seizures. INTERPRETATION Such seizures may have a wide spectre of causes, including chronic psychological conflicts and psychotraumas. Treatment should therefore be tailored to individuals.
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Affiliation(s)
- Caroline Lund
- Epilepsisenteret - SSE Nevrologisk avdeling, Oslo, Norway.
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Bodde NMG, Brooks JL, Baker GA, Boon PAJM, Hendriksen JGM, Mulder OG, Aldenkamp AP. Psychogenic non-epileptic seizures--definition, etiology, treatment and prognostic issues: a critical review. Seizure 2009; 18:543-53. [PMID: 19682927 DOI: 10.1016/j.seizure.2009.06.006] [Citation(s) in RCA: 199] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2008] [Revised: 04/10/2009] [Accepted: 06/05/2009] [Indexed: 10/20/2022] Open
Abstract
In this review we systematically assess our currently available knowledge about psychogenic non-epileptic seizures (PNES) with an emphasis on the psychological mechanisms that underlie PNES, possibilities for psychological treatment as well as prognosis. Relevant studies were identified by searching the electronic databases. Case reports were not considered. 93 papers were identified; 65 of which were studies. An open non-randomized design, comparing patients with PNES to patients with epilepsy is the dominant design. A working definition for PNES is proposed. With respect to psychological etiology, a heterogeneous set of factors have been identified. Not all factors have a similar impact, though. On the basis of this review we propose a model with several factors that may interact in both the development and prolongation of PNES. These factors involve psychological etiology, vulnerability, shaping, as well as triggering and prolongation factors. A necessary first step of intervention in patients with PNES seems to be explaining the diagnosis with care. Although the evidence for the efficacy of additional treatment strategies is limited, variants of cognitive (behavioural) therapy showed to be the preferred type of treatment for most patients. The exact choice of treatment should be based on individual differences in the underlying factors. Outcome can be measured in terms of seizure occurrence (frequency, severity), but other measures might be of greater importance for the patient. Prognosis is unclear but studies consistently report that 1/3rd to 1/4th of the patients become chronic.
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Affiliation(s)
- N M G Bodde
- Epilepsy Centre Kempenhaeghe, Heeze, The Netherlands.
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LaFrance WC, Syc S. Depression and symptoms affect quality of life in psychogenic nonepileptic seizures. Neurology 2009; 73:366-71. [PMID: 19652140 PMCID: PMC2725930 DOI: 10.1212/wnl.0b013e3181b04c83] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In patients with active epilepsy, adverse medication effects and severity of depression are correlated with health-related quality of life, but seizure frequency is not. We sought to examine if the same pattern exists in patients with psychogenic nonepileptic seizures (PNES). METHODS We administered seizure calendars, quality of life (QOL) scales, depression scales, and symptom checklists to 49 patients with video EEG-confirmed PNES. Data analysis consisted of performing Pearson correlation coefficients, scatter plots, and t tests. RESULTS Depression and symptom scores significantly increased as health-related QOL scores decreased (partial correlation coefficient r = -0.73 for both comparisons), whereas seizure count was nonsignificant (partial correlation coefficient r = -0.19). CONCLUSIONS As is seen in epilepsy, patients with psychogenic nonepileptic seizures demonstrate that higher depressive symptoms and somatic symptoms are independently related to worsening quality of life (QOL); however, seizure frequency is not. Seizure frequency is an important focus in patient care and treatment trials. The findings underscore the importance of, along with seizure counts, also examining QOL, depression, and somatic symptoms in patients with seizures.
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Affiliation(s)
- W Curt LaFrance
- Departments of Neurology and Psychiatry (W.C.L.), Rhode Island Hospital, Brown Medical School, Providence, RI, USA.
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Gaynor D, Cock H, Agrawal N. Psychological treatments for functional non-epileptic attacks: a systematic review. Acta Neuropsychiatr 2009; 21:158-68. [PMID: 25384629 DOI: 10.1111/j.1601-5215.2009.00376.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE There is a lack of clarity about the most useful intervention for functional non-epileptic attacks (FNEA). Outcomes for this condition remain often poor, with considerable personal, social and economic impact. In order to guide clinical practice and future research in this area, we have performed a systematic review of the published literature on the psychological treatment of FNEA. METHODS A comprehensive literature search was carried out using key words: non-epileptic seizures; psychogenic seizures; psychogenic non-epileptic seizures; pseudoseizures; funny turns; non-epileptic attack; hysterical seizures; and pseudoepileptic. Studies specifically looking at psychological treatment of FNEA were identified. Studies of patients also having comorbid organic seizure disorders were excluded. RESULTS 17 studies that met the inclusion criteria were identified. A broad variety of psychological interventions for FNEA has been investigated. Only one randomised controlled trial has been completed to date. Existing evidence appears to suggest that various psychological treatments, including presenting the diagnosis, psychoeducation, behavioural therapies and mixed modality treatments, may be effective. CONCLUSION While a range of psychological treatments may be beneficial for this patient group, we do not have clear evidence to suggest which treatment is most efficacious. Specific elements of presenting the diagnosis and psychoeducation may be required in addition to traditional cognitive behavioural therapeutic approaches. Large, methodologically robust studies are urgently required to establish the most effective form of treatment.
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Affiliation(s)
- Danielle Gaynor
- 1Department of Neuropsychiatry, St George's Hospital, London, UK
| | - Hannah Cock
- 2Department of Neurology, St George's University of London, London, UK
| | - Niruj Agrawal
- 1Department of Neuropsychiatry, St George's Hospital, London, UK
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Rosso OA, Mendes A, Berretta R, Rostas JA, Hunter M, Moscato P. Distinguishing childhood absence epilepsy patients from controls by the analysis of their background brain electrical activity (II): A combinatorial optimization approach for electrode selection. J Neurosci Methods 2009; 181:257-67. [DOI: 10.1016/j.jneumeth.2009.04.028] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2009] [Revised: 04/28/2009] [Accepted: 04/30/2009] [Indexed: 11/30/2022]
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Clinical features of psychogenic non-epileptic seizures in prepubertal and pubertal patients with idiopathic epilepsy. Neurol Sci 2009; 30:319-23. [DOI: 10.1007/s10072-009-0107-x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Accepted: 05/27/2009] [Indexed: 10/20/2022]
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Psychogenic non-epileptic seizures—Diagnostic issues: A critical review. Clin Neurol Neurosurg 2009; 111:1-9. [DOI: 10.1016/j.clineuro.2008.09.028] [Citation(s) in RCA: 89] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2007] [Revised: 09/23/2008] [Accepted: 09/25/2008] [Indexed: 11/23/2022]
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Rosso OA, Mendes A, Rostas JA, Hunter M, Moscato P. Distinguishing childhood absence epilepsy patients from controls by the analysis of their background brain electrical activity. J Neurosci Methods 2008; 177:461-8. [PMID: 19013193 DOI: 10.1016/j.jneumeth.2008.10.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 10/10/2008] [Accepted: 10/13/2008] [Indexed: 10/21/2022]
Abstract
Background electroencephalography (EEG), recorded with scalp electrodes, in children with childhood absence epilepsy (CAE) and control individuals has been analyzed. We considered 5 CAE patients, all right-handed females and aged 6-8 years. The 15 control individuals had the same characteristics of the CAE ones, but presented a normal EEG. The EEG was obtained using bipolar connections from a standard 10-20 electrode placement (Fp1, Fp2, F7, F3, Fz, F4, F8, T3, C3, Cz, C4, T4, T5, P3, Pz, P4, T6, O1 and O2). Recordings were undertaken in the resting state with eyes closed. EEG hallmarks of absence seizure activity are widely accepted, but there is a recognition that the bulk of interictal EEG in CAE appears normal to visual inspection. The functional activity between electrodes was evaluated using a wavelet decomposition in conjunction with the Wootters distance. Then, pairs of electrodes with differentiated behavior between CAE and controls were identified using a test statistic-based feature selection technique. This approach identified clear differences between CAE and healthy control background EEG in the frontocentral electrodes, as measured by Principal Component Analysis. The findings of this pilot study can have strong implications in future clinical practice.
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Affiliation(s)
- Osvaldo A Rosso
- Centre for Bioinformatics, Biomarker Discovery and Information-Based Medicine and Hunter Medical Research Institute, School of Electrical Engineering and Computer Science, The University of Newcastle, Callaghan, NSW 2308, Australia.
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Abstract
Narcolepsy is a common disorder with a prevalence of 0.56/1000. Patients present with a classic tetrad of excessive daytime sleepiness, cataplexy, sleep paralysis and hypnagogic hallucinations, which is seen only rarely in children. The term ;narcolepsy' is taken from Greek and means ;seized by somnolence'; it was first described in 1880 by Gelineau. This article is a case study of an 11-year-old male with pseudonarcolepsy. He presented to accident and emergency with episodes of falling asleep at inappropriate and unexpected times, often falling to the floor. Pseudonarcolepsy is a term coined to describe the phenomenon in which a patient presents with the symptoms and signs of narcolepsy, but the origin is psychogenic. Differential diagnosis, investigation and possible aetiology are discussed, along with treatment and outcome.
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Jans T, Schneck-Seif S, Weigand T, Schneider W, Ellgring H, Wewetzer C, Warnke A. Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence. Child Adolesc Psychiatry Ment Health 2008; 2:19. [PMID: 18651951 PMCID: PMC2517058 DOI: 10.1186/1753-2000-2-19] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2008] [Accepted: 07/23/2008] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Thomas Jans
- University of Wuerzburg, University Hospital, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Wuerzburg, Germany.
| | - Stefanie Schneck-Seif
- University of Wuerzburg, University Hospital, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Fuechsleinstr.15, D-97080 Wuerzburg, Germany
| | - Tobias Weigand
- University of Wuerzburg, University Hospital, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Fuechsleinstr.15, D-97080 Wuerzburg, Germany
| | - Wolfgang Schneider
- University of Wuerzburg, Department of Psychology – Educational Psychology, Roentgenring 10, D-97070 Wuerzburg, Germany
| | - Heiner Ellgring
- University of Wuerzburg, Department of Psychology – Psychological Intervention, Behavior Analysis and Regulation of Behavior, Marcusstraße 9-11, D-97070 Wuerzburg, Germany
| | - Christoph Wewetzer
- Municipal Hospitals of Cologne, Clinic for Child and Adolescent Psychiatry and Psychotherapy, Florentine-Eichler-Str. 1, D-51067 Koeln, Germany
| | - Andreas Warnke
- University of Wuerzburg, University Hospital, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Fuechsleinstr.15, D-97080 Wuerzburg, Germany
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Reuber M. Psychogenic nonepileptic seizures: answers and questions. Epilepsy Behav 2008; 12:622-35. [PMID: 18164250 DOI: 10.1016/j.yebeh.2007.11.006] [Citation(s) in RCA: 164] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2007] [Accepted: 11/18/2007] [Indexed: 10/22/2022]
Abstract
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.
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Affiliation(s)
- Markus Reuber
- Academic Neurology Unit, University of Sheffield/Royal Hallamshire Hospital, Glossop Road, Sheffield, South Yorkshire S10 2JF, UK.
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Chapter 20 Psychiatric Comorbidities in Epilepsy. INTERNATIONAL REVIEW OF NEUROBIOLOGY 2008; 83:347-83. [DOI: 10.1016/s0074-7742(08)00020-2] [Citation(s) in RCA: 136] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Binder LM, Salinsky MC. Psychogenic nonepileptic seizures. Neuropsychol Rev 2007; 17:405-12. [PMID: 18041588 DOI: 10.1007/s11065-007-9047-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2007] [Accepted: 10/05/2007] [Indexed: 11/26/2022]
Abstract
Neurological, neurodiagnostic, and neuropsychological aspects of psychogenic nonepileptic seizures (PNES) are reviewed, including psychosocial, psychiatric, cognitive, and MMPI-2 findings.
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LaFrance WC, Blum AS, Miller IW, Ryan CE, Keitner GI. Methodological issues in conducting treatment trials for psychological nonepileptic seizures. J Neuropsychiatry Clin Neurosci 2007; 19:391-8. [PMID: 18070841 PMCID: PMC2777885 DOI: 10.1176/jnp.2007.19.4.391] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A randomized, placebo-controlled trial has yet to be completed in patients with psychological nonepileptic seizures (NES). Treatment publications for NES are limited to class III trials and class IV reports. Little is written on the methodology of treatment trials in NES. The authors describe the procedures and limitations of such a trial to inform future NES treatment trials, based on their prospective, open-label pharmacological, feasibility trial. The authors review the recruitment, enrollment, completion of surveys, compliance, and follow-up of patients with NES. The majority of patients who enrolled, readily completed surveys and took the medication during the trial. Twelve patients were screened, eight enrolled, and six completed the trial. The authors discuss the use of outcomes and the various symptoms scales in the trial. A comprehensive neuropsychiatric initial assessment and assessing cognitive, emotional, behavioral, and psychosocial measures are important for monitoring the outcomes in NES treatment RCTs.
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Affiliation(s)
- W. Curt LaFrance
- Department of Neurology and the Comprehensive Epilepsy Program, Brown Medical School, Providence, Rhode Island, Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island
| | - Andrew S. Blum
- Department of Neurology and the Comprehensive Epilepsy Program, Brown Medical School, Providence, Rhode Island
| | - Ivan W. Miller
- Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island
| | - Christine E. Ryan
- Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island
| | - Gabor I. Keitner
- Department of Psychiatry and Human Behavior, Brown Medical School, Providence, Rhode Island
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Kozlowska K, Nunn KP, Rose D, Morris A, Ouvrier RA, Varghese J. Conversion disorder in Australian pediatric practice. J Am Acad Child Adolesc Psychiatry 2007; 46:68-75. [PMID: 17195731 DOI: 10.1097/01.chi.0000242235.83140.1f] [Citation(s) in RCA: 120] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the incidence and clinical features of children presenting to Australian child health specialists with conversion disorder. METHOD Active, national surveillance of conversion disorder in children younger than 16 years of age during 2002 and 2003. RESULTS A total of 194 children were reported on. The average age was 11.8 years; 23% were younger than 10 years of age. Presentations were complex, with 55% presenting with multiple conversion symptoms. The most common presentations were disturbance of voluntary motor function (64%), sensory symptoms (24%), pseudoseizure (23%), and respiratory problems (14%). Hospital admission was required for 70%, with an average stay of 10.2 days. Antecedent stressors were also reported in 62% and a history of mental health concerns in 42%, with 14% of children taking psychotropic medications for comorbid anxiety or depression. The incidence of conversion disorder in Australian specialist child health practice is estimated to be between 2.3 and 4.2/100,000. CONCLUSIONS Conversion disorder is associated with a significant burden for the child, family, and the health system. This study emphasizes the comorbidity with anxiety, depression, and symptoms of pain and fatigue. It also highlights the potential impact of "commonplace" stressors such as family conflict and children's loss of attachment figures.
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Affiliation(s)
- Kasia Kozlowska
- Dr. Kozlowska and Ms. Rose are with the Department of Psychological Medicine, The Children Hospital at Westmead, Sydney, Australia; Professor Nunn is with Nexus, John Hunter Hospital, Newcastle, Australia; Dr. Morris and Professor Ouvrier are with the Department of Paediatrics and Child Health, The Children Hospital at Westmead and University of Sydney; and Dr. Varghese is with the Child and Family Therapy Unit, Royal Children's Hospital, Brisbane, Australia..
| | - Kenneth P Nunn
- Dr. Kozlowska and Ms. Rose are with the Department of Psychological Medicine, The Children Hospital at Westmead, Sydney, Australia; Professor Nunn is with Nexus, John Hunter Hospital, Newcastle, Australia; Dr. Morris and Professor Ouvrier are with the Department of Paediatrics and Child Health, The Children Hospital at Westmead and University of Sydney; and Dr. Varghese is with the Child and Family Therapy Unit, Royal Children's Hospital, Brisbane, Australia
| | - Donna Rose
- Dr. Kozlowska and Ms. Rose are with the Department of Psychological Medicine, The Children Hospital at Westmead, Sydney, Australia; Professor Nunn is with Nexus, John Hunter Hospital, Newcastle, Australia; Dr. Morris and Professor Ouvrier are with the Department of Paediatrics and Child Health, The Children Hospital at Westmead and University of Sydney; and Dr. Varghese is with the Child and Family Therapy Unit, Royal Children's Hospital, Brisbane, Australia
| | - Anne Morris
- Dr. Kozlowska and Ms. Rose are with the Department of Psychological Medicine, The Children Hospital at Westmead, Sydney, Australia; Professor Nunn is with Nexus, John Hunter Hospital, Newcastle, Australia; Dr. Morris and Professor Ouvrier are with the Department of Paediatrics and Child Health, The Children Hospital at Westmead and University of Sydney; and Dr. Varghese is with the Child and Family Therapy Unit, Royal Children's Hospital, Brisbane, Australia
| | - Robert A Ouvrier
- Dr. Kozlowska and Ms. Rose are with the Department of Psychological Medicine, The Children Hospital at Westmead, Sydney, Australia; Professor Nunn is with Nexus, John Hunter Hospital, Newcastle, Australia; Dr. Morris and Professor Ouvrier are with the Department of Paediatrics and Child Health, The Children Hospital at Westmead and University of Sydney; and Dr. Varghese is with the Child and Family Therapy Unit, Royal Children's Hospital, Brisbane, Australia
| | - John Varghese
- Dr. Kozlowska and Ms. Rose are with the Department of Psychological Medicine, The Children Hospital at Westmead, Sydney, Australia; Professor Nunn is with Nexus, John Hunter Hospital, Newcastle, Australia; Dr. Morris and Professor Ouvrier are with the Department of Paediatrics and Child Health, The Children Hospital at Westmead and University of Sydney; and Dr. Varghese is with the Child and Family Therapy Unit, Royal Children's Hospital, Brisbane, Australia
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