Seizure 25 (2015) 95–98
Contents lists available at ScienceDirect
Seizure journal homepage: www.elsevier.com/locate/yseiz
Co-morbidities and outcome of childhood psychogenic non-epileptic seizures––An observational study Vikram Singh Rawat a, Vikas Dhiman b,c, Sanjib Sinha c,*, Kommu John Vijay Sagar d, Harish Thippeswamy a, Santosh Kumar Chaturvedi a, Shoba Srinath d, Parthasarthy Satishchandra c a
Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India Department of Clinical Neurosciences, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India c Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India d Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 May 2014 Received in revised form 24 September 2014 Accepted 26 September 2014
Purpose: To assess the psychiatric diagnoses and outcome in children with psychogenic non-epileptic seizures (PNES). Methodology: This hospital based observational study was performed on 44 children aged 1 AEDs while 11 children (32.4%) were on single AED at the time of the initial evaluation. 4.3. Co-morbid epilepsy Eight (8/34, 23.5%, M:F = 5:3) children were diagnosed to have both psychogenic non-epileptic seizures and epilepsy. The mean age at onset for epilepsy and PNES was 7.6 3.2 years and 12 3.5 years respectively. They were followed up for 10 6 months (range: 0–18 months). The commonest seizure type was complex partial (n = 4, 50.0%) followed by generalized (n = 3, 37.5%) and simple partial (n = 1, 12.5%). EEG abnormalities were noted in all 8 children. Five children (62.5%) were on two AEDs, 2 (25.0%) were on three AEDs while 1 (12.5%) child was on four AEDs. The abnormalities noted on the brain MRI in this cohort of patient were: mesial temporal sclerosis (MTS): 2 children; focal lesions: 3 children (right inferior frontal gyrus gliosis, right inferior frontal gyrus cortical dysplasia, right frontal ring enhancing lesion), while MRI was normal in rest of 3 children (Tables 1 and 2). All the 8 children with combined ‘epilepsy with PNES’ had underlying conversion disorder. Psychological assessments were carried out in four children (50.0%). One child (12.5%) was found to have low intelligence (mild intellectual disability) while 3 children (37.5%) had co-morbid psychiatric disorder, e.g. ADHD, intellectual disability, specific learning disorder, depression and adjustment disorder, which could be responsible for their PNES. Four children had no recurrence of the PNES attacks, while three had reduced
Table 1 Socio-demographic details of children with PNES. Patient-related characteristics in PNESs (n = 34)
N (%)
Education Preschool or primary school High school Pre-university Positive history of anxiety disorder Positive history of mood disorder Positive history of self-harm Positive family history of seizures Positive family history of psychiatric disorders Co-existent neurological deficit Coexistent systemic complaint Headache
19 13 2 4 4 4 7 3 4 9 5
(55.9) (38.2) (5.9) (11.8) (11.8) (11.8) (20.6) (8.8) (11.8) (26.5) (14.7)
Table 2 Details of psychiatric diagnosis among children. Diagnosis (total = 44) PNES Conversion disorder Other diagnosis Attention Deficit Hyperactivity Disorder (ADHD) Gratification disorder Specific learning disorder Night terrors Hypersomnolence Cold precipitating dyskinesia Isovaleric aciduria
N (%) 34 (77.3) 3 2 1 1 1 1 1
(6.8) (4.5) (2.3) (2.3) (2.3) (2.3) (2.3)
5. Discussion
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Funding None. Conflict of interest None declared. Acknowledgements We acknowledge the contributions of the staffs of the epilepsymonitoring unit, Department of Neurology. Last but not the least, we are grateful to the subjects for allowing us to carry out such study. References 1. Bodde NM, Brooks JL, Baker GA, Boon PA, Hendriksen JG, Aldenkamp AP. Psychogenic non-epileptic seizures – diagnostic issues: a critical review. Clin Neurol Neurosurg 2009;111:1–9. 2. Reuber M. Psychogenic nonepileptic seizures: diagnosis, aetiology, treatment and prognosis. Schweiz Arch Neurol Psychiatr 2005;156:47–57. 3. Gates JR. Non-epileptic seizures classification co-existence with epilepsy: diagnosis, therapeutic approaches and consensus. Epilepsy Behav 2002;3: 28–33. 4. Rao TS. Paroxysmal non-epileptic seizures in children: recognition and approach to diagnosis. Adv Clin Neurosci Rehabil 2012;12:17–20. 5. Beach R, Reading R. The importance of acknowledging clinical uncertainty in the diagnosis of epilepsy and non-epileptic events. Arch Dis Child 2005;90:1212–22. 6. Desai P, Talwar D. Non-epileptic events in normal and neurologically handicapped children: a video-EEG study. Pediatr Neurol 1992;8:127–9. 7. Bye AM, Nunan J. Video EEG analysis of non-ictal events in children. Clin Exp Neurol 1992;29:92–8. 8. Bye AM, Kok DJ, Ferenschild FT, Vles JS. Paroxysmal non-epileptic events in children: a retrospective study over a period of 10 years. J Paediatr Child Health 2000;36:244–8. 9. Uldall P, Alving J, Hansen LK, Kibaek M, Buchholt J. The misdiagnosis of epilepsy in children admitted to a tertiary epilepsy centre with paroxysmal events. Arch Dis Child 2006;9:219–21.
10. Seneviratne U, Briggs B, Lowenstern D, D’Souza W. The spectrum of psychogenic non-epileptic seizures and comorbidities seen in an epilepsy monitoring unit. J Clin Neurosci 2011;18:361–3. 11. Kotagal P, Costa M, Wyllie E, Wolgamuth B. Paroxysmal non-epileptic events in children and adolescents. Pediatrics 2002;110:e46. 12. Kuyk J, Leijten F, Meinardi H, Spinhoven. Van Dyck R. The diagnosis of psychogenic non-epileptic seizures: a review. Seizure 1997;6:243–53. 13. Allen JE, Ferrie CD, Livingston JH, Feltbower RG. Recovery of consciousness after epileptic seizures in children. Arch Dis Child 2007;92:39–42. 14. Moore PM, Baker GA. Non-epileptic attack disorder: a psychological perspective. Seizure 1997;6:429–34. 15. Irwin K, Edwards M, Robinson R. Psychogenic non-epileptic seizures: management and prognosis. Arch Dis Child 2000;82:474–8. 16. Wyllie E, Friedman D, Rothner AD, Luders H, Dinner D, Morris H, et al. Psychogenic seizures in children and adolescents: outcome after diagnosis by ictal video and electroencephalographic recording. Pediatrics 1990;85: 480–4. 17. Ettinger AB, Devinsky O, Weisbrot DM, Ramakrishna RK, Goyal A. A comprehensive profile of clinical, psychiatric, and psychosocial characteristics of patients with psychogenic nonepileptic seizures. Epilepsia 1999;40:1292–8. 18. Reuber M, Pukrop R, Bauer J, Helmstaedter C, Tessendorf N, Elger CE. Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol 2003;53:305–11. 19. Chinta SS, Malhi P, Singhi P, Prabhakar S. Clinical and psychosocial characteristics of children with non-epileptic seizures. Ann Indian Acad Neurol 2008;11: 159–63. 20. Seneviratne U, Reutens D, D’Souza W. Stereotypy of psychogenic nonepileptic seizures: insights from video-EEG monitoring. Epilepsia 2010;51:1159–68. 21. Benbadis SR, Allen Hauser W. An estimate of the prevalence of psychogenic non-epileptic seizures. Seizure 2000;9:280–1. 22. Prabhuswamy M, Jairam R, Srinath S, Girimaji S, Seshadri SP. A systematic chart review of inpatient population with childhood dissociative disorder. J Indian Assoc Child Adolesc Ment Health 2006;2:72–7. 23. Dhiman V, Sinha S, Rawat VS, Vijaysagar KJ, Thippeswamy H, Srinath S, et al. Children with psychogenic non-epileptic seizures (PNES): a detailed semiologic analysis and modified new classification. Brain Dev 2014;36:287–93. 24. Malhi P, Singhi P. Clinical characteristics and outcome of children and adolescents with conversion disorder. Indian Pediatr 2002;39:747–52. 25. Srinath S, Bharat S, Girimaji S, Seshadri S. Characteristics of a child inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993;32: 822–5. 26. Leung AK, Robson WL. Childhood masturbation. Clin Pediatr (Phila) 1993;32: 238–41. 27. Nechay A, Ross LM, Stephenson JB, O’Regan M. Gratification disorder (infantile masturbation): a review. Arch Dis Child 2000;89:225–6.
Contents lists available at ScienceDirect
Seizure journal homepage: www.elsevier.com/locate/yseiz
Co-morbidities and outcome of childhood psychogenic non-epileptic seizures––An observational study Vikram Singh Rawat a, Vikas Dhiman b,c, Sanjib Sinha c,*, Kommu John Vijay Sagar d, Harish Thippeswamy a, Santosh Kumar Chaturvedi a, Shoba Srinath d, Parthasarthy Satishchandra c a
Department of Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India Department of Clinical Neurosciences, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India c Department of Neurology, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India d Department of Child and Adolescent Psychiatry, National Institute of Mental Health and Neurosciences (NIMHANS), Bangalore, India b
A R T I C L E I N F O
A B S T R A C T
Article history: Received 29 May 2014 Received in revised form 24 September 2014 Accepted 26 September 2014
Purpose: To assess the psychiatric diagnoses and outcome in children with psychogenic non-epileptic seizures (PNES). Methodology: This hospital based observational study was performed on 44 children aged 1 AEDs while 11 children (32.4%) were on single AED at the time of the initial evaluation. 4.3. Co-morbid epilepsy Eight (8/34, 23.5%, M:F = 5:3) children were diagnosed to have both psychogenic non-epileptic seizures and epilepsy. The mean age at onset for epilepsy and PNES was 7.6 3.2 years and 12 3.5 years respectively. They were followed up for 10 6 months (range: 0–18 months). The commonest seizure type was complex partial (n = 4, 50.0%) followed by generalized (n = 3, 37.5%) and simple partial (n = 1, 12.5%). EEG abnormalities were noted in all 8 children. Five children (62.5%) were on two AEDs, 2 (25.0%) were on three AEDs while 1 (12.5%) child was on four AEDs. The abnormalities noted on the brain MRI in this cohort of patient were: mesial temporal sclerosis (MTS): 2 children; focal lesions: 3 children (right inferior frontal gyrus gliosis, right inferior frontal gyrus cortical dysplasia, right frontal ring enhancing lesion), while MRI was normal in rest of 3 children (Tables 1 and 2). All the 8 children with combined ‘epilepsy with PNES’ had underlying conversion disorder. Psychological assessments were carried out in four children (50.0%). One child (12.5%) was found to have low intelligence (mild intellectual disability) while 3 children (37.5%) had co-morbid psychiatric disorder, e.g. ADHD, intellectual disability, specific learning disorder, depression and adjustment disorder, which could be responsible for their PNES. Four children had no recurrence of the PNES attacks, while three had reduced
Table 1 Socio-demographic details of children with PNES. Patient-related characteristics in PNESs (n = 34)
N (%)
Education Preschool or primary school High school Pre-university Positive history of anxiety disorder Positive history of mood disorder Positive history of self-harm Positive family history of seizures Positive family history of psychiatric disorders Co-existent neurological deficit Coexistent systemic complaint Headache
19 13 2 4 4 4 7 3 4 9 5
(55.9) (38.2) (5.9) (11.8) (11.8) (11.8) (20.6) (8.8) (11.8) (26.5) (14.7)
Table 2 Details of psychiatric diagnosis among children. Diagnosis (total = 44) PNES Conversion disorder Other diagnosis Attention Deficit Hyperactivity Disorder (ADHD) Gratification disorder Specific learning disorder Night terrors Hypersomnolence Cold precipitating dyskinesia Isovaleric aciduria
N (%) 34 (77.3) 3 2 1 1 1 1 1
(6.8) (4.5) (2.3) (2.3) (2.3) (2.3) (2.3)
5. Discussion
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Funding None. Conflict of interest None declared. Acknowledgements We acknowledge the contributions of the staffs of the epilepsymonitoring unit, Department of Neurology. Last but not the least, we are grateful to the subjects for allowing us to carry out such study. References 1. Bodde NM, Brooks JL, Baker GA, Boon PA, Hendriksen JG, Aldenkamp AP. Psychogenic non-epileptic seizures – diagnostic issues: a critical review. Clin Neurol Neurosurg 2009;111:1–9. 2. Reuber M. Psychogenic nonepileptic seizures: diagnosis, aetiology, treatment and prognosis. Schweiz Arch Neurol Psychiatr 2005;156:47–57. 3. Gates JR. Non-epileptic seizures classification co-existence with epilepsy: diagnosis, therapeutic approaches and consensus. Epilepsy Behav 2002;3: 28–33. 4. Rao TS. Paroxysmal non-epileptic seizures in children: recognition and approach to diagnosis. Adv Clin Neurosci Rehabil 2012;12:17–20. 5. Beach R, Reading R. The importance of acknowledging clinical uncertainty in the diagnosis of epilepsy and non-epileptic events. Arch Dis Child 2005;90:1212–22. 6. Desai P, Talwar D. Non-epileptic events in normal and neurologically handicapped children: a video-EEG study. Pediatr Neurol 1992;8:127–9. 7. Bye AM, Nunan J. Video EEG analysis of non-ictal events in children. Clin Exp Neurol 1992;29:92–8. 8. Bye AM, Kok DJ, Ferenschild FT, Vles JS. Paroxysmal non-epileptic events in children: a retrospective study over a period of 10 years. J Paediatr Child Health 2000;36:244–8. 9. Uldall P, Alving J, Hansen LK, Kibaek M, Buchholt J. The misdiagnosis of epilepsy in children admitted to a tertiary epilepsy centre with paroxysmal events. Arch Dis Child 2006;9:219–21.
10. Seneviratne U, Briggs B, Lowenstern D, D’Souza W. The spectrum of psychogenic non-epileptic seizures and comorbidities seen in an epilepsy monitoring unit. J Clin Neurosci 2011;18:361–3. 11. Kotagal P, Costa M, Wyllie E, Wolgamuth B. Paroxysmal non-epileptic events in children and adolescents. Pediatrics 2002;110:e46. 12. Kuyk J, Leijten F, Meinardi H, Spinhoven. Van Dyck R. The diagnosis of psychogenic non-epileptic seizures: a review. Seizure 1997;6:243–53. 13. Allen JE, Ferrie CD, Livingston JH, Feltbower RG. Recovery of consciousness after epileptic seizures in children. Arch Dis Child 2007;92:39–42. 14. Moore PM, Baker GA. Non-epileptic attack disorder: a psychological perspective. Seizure 1997;6:429–34. 15. Irwin K, Edwards M, Robinson R. Psychogenic non-epileptic seizures: management and prognosis. Arch Dis Child 2000;82:474–8. 16. Wyllie E, Friedman D, Rothner AD, Luders H, Dinner D, Morris H, et al. Psychogenic seizures in children and adolescents: outcome after diagnosis by ictal video and electroencephalographic recording. Pediatrics 1990;85: 480–4. 17. Ettinger AB, Devinsky O, Weisbrot DM, Ramakrishna RK, Goyal A. A comprehensive profile of clinical, psychiatric, and psychosocial characteristics of patients with psychogenic nonepileptic seizures. Epilepsia 1999;40:1292–8. 18. Reuber M, Pukrop R, Bauer J, Helmstaedter C, Tessendorf N, Elger CE. Outcome in psychogenic nonepileptic seizures: 1 to 10-year follow-up in 164 patients. Ann Neurol 2003;53:305–11. 19. Chinta SS, Malhi P, Singhi P, Prabhakar S. Clinical and psychosocial characteristics of children with non-epileptic seizures. Ann Indian Acad Neurol 2008;11: 159–63. 20. Seneviratne U, Reutens D, D’Souza W. Stereotypy of psychogenic nonepileptic seizures: insights from video-EEG monitoring. Epilepsia 2010;51:1159–68. 21. Benbadis SR, Allen Hauser W. An estimate of the prevalence of psychogenic non-epileptic seizures. Seizure 2000;9:280–1. 22. Prabhuswamy M, Jairam R, Srinath S, Girimaji S, Seshadri SP. A systematic chart review of inpatient population with childhood dissociative disorder. J Indian Assoc Child Adolesc Ment Health 2006;2:72–7. 23. Dhiman V, Sinha S, Rawat VS, Vijaysagar KJ, Thippeswamy H, Srinath S, et al. Children with psychogenic non-epileptic seizures (PNES): a detailed semiologic analysis and modified new classification. Brain Dev 2014;36:287–93. 24. Malhi P, Singhi P. Clinical characteristics and outcome of children and adolescents with conversion disorder. Indian Pediatr 2002;39:747–52. 25. Srinath S, Bharat S, Girimaji S, Seshadri S. Characteristics of a child inpatient population with hysteria in India. J Am Acad Child Adolesc Psychiatry 1993;32: 822–5. 26. Leung AK, Robson WL. Childhood masturbation. Clin Pediatr (Phila) 1993;32: 238–41. 27. Nechay A, Ross LM, Stephenson JB, O’Regan M. Gratification disorder (infantile masturbation): a review. Arch Dis Child 2000;89:225–6.
