Psychogenic non-epileptic seizures in children and adolescents: Part II – explanations to families, treatment, and group outcomes

Abstract

Psychogenic non-epileptic seizures (PNES) – time-limited disturbances of consciousness and motor-sensory control, not accompanied by ictal activity on electroencephalogram (EEG) – are best conceptualized as atypical neurophysiological responses to emotional distress, physiological stressors and danger. Patients and families find the diagnosis of PNES difficult to understand; the transition from neurology (where the diagnosis is made) to mental health services (to which patients are referred for treatment) can be a bumpy one. This study reports how diagnostic formulations constructed for 60 consecutive children and adolescents with PNES were used to inform both the explanations about PNES that were given to them and their families and the clinical interventions that were used to help patients gain control over PNES. Families were able to accept the diagnosis of PNES and engage in treatment when it was explained how emotional distress, illness and states of high arousal could activate atypical defence responses in the body and brain – with PNES being an unwanted by-product of this process. Patients and their families made good use of therapeutic interventions. A total of 75% of children/adolescents (45/60) regained normal function and attained full-time return to school. Global Assessment of Functioning scores increased from 41 to 67 (t(54) = 10.09; p < .001). Outcomes were less favourable in children/adolescents who presented with chronic PNES and in those with a chronic, comorbid mental health disorder that failed to resolve with treatment. The study highlights that prompt diagnosis, followed by prompt multidisciplinary assessment, engagement, and treatment, achieves improved outcomes in children/adolescents with PNES.

Morbidity and mortality of nonepileptic seizures (NES): A controlled national study

“…The strongest and most important finding in this study is the raised prevalence of comorbidities involving psychiatric diseases (depression, anxiety) and in dissociative and somatoform conditions. Case-based observations have highlighted the high frequency of specific psychological profiles [5,[18][19][20][21], and the high rates of depression, anxiety, and somatoform conditions [18,22,23]. Somatoform patterns are also evident in this study as more patients showed a greater number of contacts with the healthcare system due to lipothymias, abnormal nonepileptic movements, symptoms of multiple organ system and minor traumas.…”

Psychogenic Non-Epileptic Status as Refractory, Generalized Hypertonic Posturing: Report of Two Adolescents

“…Both adolescents showed symptoms associated with the respiratory system, e.g., difficult breathing and gasping. A recent study of children and adolescents with PNES showed that a significant percentage triggered their PNES via hyperventilation and showed abnormal regulation of PCO 2 [ 28 ]. In neither of the cases in this study was a blood CO 2 reading taken to assess for hypocapnia that could have been contributing to the dystonic symptom patterns and changes in level of consciousness [ 29 ].…”

“…It should be noted that there seems to be significant overlap between panic attacks, which involve abnormal breathing patterns, and psychogenic seizures [ 30 ]. It is possible that breathing interventions that targeted arousal, a decrease in respiratory rate, and normalization of ventilation and arterial CO 2 could have been helpful preventing or managing the PNES in the two adolescents described in this report [ 28 ].…”

Psychogenic non-epileptic seizures in children and adolescents: Part I – Diagnostic formulations

“…This study, Part I of a two-part article, presents the diagnostic formulations – the clinical formulations about the probable neurophysiological mechanisms, known or hypothesized – that were constructed for 60 consecutive children and adolescents with PNES who were referred to our Mind-Body Rehabilitation Programme for treatment. In Part II, we use the formulations presented here to frame discussions with patients and families, and to identify what treatments are most likely to help patients diagnosed with particular subtypes of PNES ( Kozlowska, Chudleigh, et al, 2017 ).…”