Accepted Manuscript Psychogenic Paroxysmal Non-Epileptic Events in Children – A Review Lindsey A. Morgan, MD, Jeffrey Buchhalter, MD, PhD PII:
S0887-8994(15)00157-5
DOI:
10.1016/j.pediatrneurol.2015.03.017
Reference:
PNU 8630
To appear in:
Pediatric Neurology
Received Date: 29 August 2014 Revised Date:
28 October 2014
Accepted Date: 17 March 2015
Please cite this article as: Morgan LA, Buchhalter J, Psychogenic Paroxysmal Non-Epileptic Events in Children – A Review, Pediatric Neurology (2015), doi: 10.1016/j.pediatrneurol.2015.03.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Psychogenic Paroxysmal Non-Epileptic Events in Children – A Review
RI PT
Running title: Psychogenic events in children
SC
MS#: PNU-D-14-00467
Jeffrey Buchhalter MD, PhDb
& Robert H. Lurie Children’s Hospital of Chicago
225 E. Chicago Ave
EP
Chicago, IL 60611
TE D
a Ann
M AN U
Lindsey A. Morgan MDa
[email protected]
AC C
Phone 312-227-3550 Fax 312-227-9642
Email: [email protected]
b (Corresponding
Author)
1
ACCEPTED MANUSCRIPT
Alberta Children's Hospital
RI PT
2888 Shaganappi Trail NW T3B 6A8
SC
Calgary, AB
M AN U
Canada
Email: [email protected]
403-955-7649
EP
FAX
TE D
Phone 403-955-2296
Word Count: 5471 (Excluding Abstract and References)
AC C
Title: 66 characters with spaces
Running title: 30 characters with spaces Abstract: 172 words References: 83
2
ACCEPTED MANUSCRIPT
Abstract: Paroxysmal non-epileptic events are common in children. Events with a
RI PT
psychological basis, historically referred to as pseudoseizures, are a large subset of paroxysmal non-epileptic events. These events have many semiologic features similar to epileptic events and can be challenging to correctly identify. The use of a
SC
detailed history in combination with video EEG and knowledge of psychogenic paroxysmal non-epileptic events (PNEs), will facilitate making the correct
M AN U
diagnosis. PNEs are important to identify as co-morbid 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. Pediatric patients with PNEs need to be recognized so as to limit the use of unnecessary anti-
TE D
epileptic drugs and emergency department or hospital visits, as well as getting the patients appropriate psychological intervention to address the underlying etiologies. This review will focus on evaluation and identification of PNEs, in addition to
EP
reviewing the various co-morbidities, effective treatments, and outcomes for pediatric patients. The key differences between pediatric and adult patients with
AC C
PNEs are addressed. Keywords:
psychogenic,
paroxysmal,
non-epileptic,
seizures,
video
EEG,
pseudoseizures
3
ACCEPTED MANUSCRIPT
Psychogenic Paroxysmal Non-Epileptic Events in Children – A Review
RI PT
This review will focus on psychogenic paroxysmal non-epileptic events (PNEs) in the pediatric population, although reference will be made to the adult literature
frequently included in adult studies.
M AN U
Background
SC
both for comparison purposes and to address the reality that older adolescents are
There are many types of PNEs that can be classified as physiologic or psychological. Age and semiology can help to differentiate the various etiologies (see table 1). For the remainder of this article, discussion of PNEs is assumed to be of a psychogenic
TE D
etiology unless stated otherwise. Psychogenic non-epileptic seizures are identified in DSM V, under the title of “conversion disorder/functional neurological symptom disorder”. The event is defined as not intentionally produced or feigned, affecting
EP
voluntary motor or sensory function, causing significant distress, psychosocial impairment and warranting medical evaluation, and not able to be fully explained
AC C
by a neurologic or a general medical condition.1 Clinicians should suspect PNEs when attacks are frequent despite medical management, have atypical clinical features, or multiple EEGs with normal results.2,3 Compared to patients with epilepsy, patients with PNEs exhibit more frequent, severe, and disabling events and an overall poorer quality of life.4 Although advancements have been made in
4
ACCEPTED MANUSCRIPT
the diagnosis and treatment of epilepsy, PNEs are often still the source of diagnostic frustration.
RI PT
Epidemiology and Demographics The prevalence of PNEs in the general population is believed to be in the range of 1/3000 to 1/50,000 although it is recognized that this maybe a low estimate due to
SC
under reporting and diagnosis.5 Another study found the mean incidence in adults over a 4 year period to be 3.03/100,000, with one year as high as 4.6/100,000.6
M AN U
Although the prevalence will vary depending upon the population studied, in general, the health care resources expended on people with PNEs constitute 10-40% of admissions to inpatient adult and pediatric epilepsy monitoring units and 5-20% of referrals for intractable epilepsy.4,7-10,11 An adult study found 18/141 (12.8%)
TE D
patients admitted to the Epilepsy Monitoring Unit (EMU) to have PNEs,12 while a combined incidence in consecutive video EEGs of adults and children documented PNE in 139/1281 (10.9%) of patients.13 Of these 139, 56 (40%) were in children
S0887-8994(15)00157-5
DOI:
10.1016/j.pediatrneurol.2015.03.017
Reference:
PNU 8630
To appear in:
Pediatric Neurology
Received Date: 29 August 2014 Revised Date:
28 October 2014
Accepted Date: 17 March 2015
Please cite this article as: Morgan LA, Buchhalter J, Psychogenic Paroxysmal Non-Epileptic Events in Children – A Review, Pediatric Neurology (2015), doi: 10.1016/j.pediatrneurol.2015.03.017. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Psychogenic Paroxysmal Non-Epileptic Events in Children – A Review
RI PT
Running title: Psychogenic events in children
SC
MS#: PNU-D-14-00467
Jeffrey Buchhalter MD, PhDb
& Robert H. Lurie Children’s Hospital of Chicago
225 E. Chicago Ave
EP
Chicago, IL 60611
TE D
a Ann
M AN U
Lindsey A. Morgan MDa
[email protected]
AC C
Phone 312-227-3550 Fax 312-227-9642
Email: [email protected]
b (Corresponding
Author)
1
ACCEPTED MANUSCRIPT
Alberta Children's Hospital
RI PT
2888 Shaganappi Trail NW T3B 6A8
SC
Calgary, AB
M AN U
Canada
Email: [email protected]
403-955-7649
EP
FAX
TE D
Phone 403-955-2296
Word Count: 5471 (Excluding Abstract and References)
AC C
Title: 66 characters with spaces
Running title: 30 characters with spaces Abstract: 172 words References: 83
2
ACCEPTED MANUSCRIPT
Abstract: Paroxysmal non-epileptic events are common in children. Events with a
RI PT
psychological basis, historically referred to as pseudoseizures, are a large subset of paroxysmal non-epileptic events. These events have many semiologic features similar to epileptic events and can be challenging to correctly identify. The use of a
SC
detailed history in combination with video EEG and knowledge of psychogenic paroxysmal non-epileptic events (PNEs), will facilitate making the correct
M AN U
diagnosis. PNEs are important to identify as co-morbid 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. Pediatric patients with PNEs need to be recognized so as to limit the use of unnecessary anti-
TE D
epileptic drugs and emergency department or hospital visits, as well as getting the patients appropriate psychological intervention to address the underlying etiologies. This review will focus on evaluation and identification of PNEs, in addition to
EP
reviewing the various co-morbidities, effective treatments, and outcomes for pediatric patients. The key differences between pediatric and adult patients with
AC C
PNEs are addressed. Keywords:
psychogenic,
paroxysmal,
non-epileptic,
seizures,
video
EEG,
pseudoseizures
3
ACCEPTED MANUSCRIPT
Psychogenic Paroxysmal Non-Epileptic Events in Children – A Review
RI PT
This review will focus on psychogenic paroxysmal non-epileptic events (PNEs) in the pediatric population, although reference will be made to the adult literature
frequently included in adult studies.
M AN U
Background
SC
both for comparison purposes and to address the reality that older adolescents are
There are many types of PNEs that can be classified as physiologic or psychological. Age and semiology can help to differentiate the various etiologies (see table 1). For the remainder of this article, discussion of PNEs is assumed to be of a psychogenic
TE D
etiology unless stated otherwise. Psychogenic non-epileptic seizures are identified in DSM V, under the title of “conversion disorder/functional neurological symptom disorder”. The event is defined as not intentionally produced or feigned, affecting
EP
voluntary motor or sensory function, causing significant distress, psychosocial impairment and warranting medical evaluation, and not able to be fully explained
AC C
by a neurologic or a general medical condition.1 Clinicians should suspect PNEs when attacks are frequent despite medical management, have atypical clinical features, or multiple EEGs with normal results.2,3 Compared to patients with epilepsy, patients with PNEs exhibit more frequent, severe, and disabling events and an overall poorer quality of life.4 Although advancements have been made in
4
ACCEPTED MANUSCRIPT
the diagnosis and treatment of epilepsy, PNEs are often still the source of diagnostic frustration.
RI PT
Epidemiology and Demographics The prevalence of PNEs in the general population is believed to be in the range of 1/3000 to 1/50,000 although it is recognized that this maybe a low estimate due to
SC
under reporting and diagnosis.5 Another study found the mean incidence in adults over a 4 year period to be 3.03/100,000, with one year as high as 4.6/100,000.6
M AN U
Although the prevalence will vary depending upon the population studied, in general, the health care resources expended on people with PNEs constitute 10-40% of admissions to inpatient adult and pediatric epilepsy monitoring units and 5-20% of referrals for intractable epilepsy.4,7-10,11 An adult study found 18/141 (12.8%)
TE D
patients admitted to the Epilepsy Monitoring Unit (EMU) to have PNEs,12 while a combined incidence in consecutive video EEGs of adults and children documented PNE in 139/1281 (10.9%) of patients.13 Of these 139, 56 (40%) were in children
