Mental Functions and Non-Epileptic Seizures in Children

1. Mental Functions and Non-Epileptic Seizures in Children Robert W. Trobliger, Ph.D. Co-Director Clinical Neuropsychology Northeast Regional Epilepsy Group

2. Non-Epileptic Seizures versus Epileptic seizures

3. Epileptic seizure • An episode typically involving uncontrolled movements or loss of awareness, often brief in duration and resulting from excessive or synchronous electrical activity in the brain • ILAE

4. Prevalence of Epilepsy in the U.S. • 2.2 million people • 7.1 for every 1000 people (0.7%) • Epilepsy Foundation • www.epilepsy.com

5. Prevalence of Diabetes in the U.S. • 29.1 million people • 9.3% • www.diabetes.org

6. Prevalence of Traumatic Brain Injury in the U.S. • Between 3.2 and 5.3 million • (1.1 – 1.7% population) • dealing with long-term disabilities related to TBI • www.asha.org

7. Prevalence of Pediatric Epilepsy cases in the U.S. • 1% children aged 0 -17 years have had a diagnosis of epilepsy or seizure disorder • About 750,000 children • Centers for Disease Control and Prevention • www.cdc.gov

8. Differential Diagnosis Epileptic Seizures versus Paroxsymal Non-epileptic Events (PNEs)

9. Differential Diagnosis • Ex: Psychogenic Non-epileptic Seizures • (PNES) • versus • pseudo-seizures • non-epileptic seizures • psychogenic seizures

10. PNEs Sudden involuntary changes in behavior, sensation or consciousness resembling epileptic seizures but not accompanied by abnormal ictal changes in the brain. Park et al (2015)

11. vascular conditions movement disorders (Parkinson's, Huntington's) gastrointestinal disorders PNEs – Organic Disorders

12. PNEs - psychiatric disorders/conditions • ADHD – inattention/daydreaming • PTSD – flashbacks and dissociative episodes • anxiety disorder/panic attacks • conversion disorder (PNES) • malingering • Reilly et al 2013

13. Psychogenic Non-epileptic Seizures (PNES) Paroxysmal events with discernible changes in behavior or consciousness but with no accompanying electrophysiologic changes.

14. Psychogenic Non-epileptic Seizures(PNES) • Involuntary • time limited • involve • motor, • sensory, • or behavioral occurrences • resemble epileptic seizures.

15. Psychogenic Non-epileptic Seizures(PNES) • alteration of consciousness • posturing • jerking of the extremities • sensory or behavioral disturbances

16. Psychogenic Non-epileptic Seizures(PNES) Underlying psychological causes behind the seizures

17. Psychogenic Non-epileptic Seizures • PNES classified as • Conversion Disorder with seizures or convulsions (DSM V) • ICD-10 diagnosis F44.5 Conversion Disorder • (with attacks or seizures)

18. Conversion Disorder DSM V One or more symptoms of altered voluntary motor or sensory function. Clinical findings provide evidence of incompatibility between the symptom and recognized neurological or medical conditions. The symptom or deficit is not better explained by another medical or mental disorder. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical condition.

19. Conversion Disorder DSM IV TR A. one or more symptoms or deficits affecting voluntary motor or sensory function that suggest a neurological or other general medical condition. B. Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors. C. The symptom or deficit is not intentionally produced or feigned.

20. Conversion Disorder D. The symptom or deficit cannot, after appropriate investigation, be fully explained by a general medical condition, or by the direct effects of a substance, or as a culturally sanctioned behavior or experience. E. The symptom or deficit causes clinically significant distress or impairment in social, occupational, or other important areas of functioning or warrants medical evaluation. F. The symptom or deficit is not limited to pain or sexual dysfunction, does not occur exclusively during the course of Somatization Disorder, and is not better accounted for by another mental disorder.

21. Conversion Disorder Somatic Disorder Somatization is the process whereby physical symptoms are experienced in response to stress.

22. PNES Statistics 5 - 20% of adults in outpatient epilepsy population

23. PNES Statistics Some questions regarding underestimating most numbers come from neurology/epilepsy centers, with VEEG studies.

24. PNES Statistics 20 - 40% children evaluated in epilepsy clinics reported to have PNES

25. PNES Statistics Estimates of prevalence of PNES in children with suspected epilepsy 1 - 9%. Rawat et al (2015) found 6.6% prevalence in children Szabo et al (2012) found 4.8% prevalence of PNES among children underwent VEEG

26. Issues with statistics Difficult to establish estimates of prevalence or incidence of PNES in childhood.

27. Issues with statistics Question if widely diagnosed outside of epilepsy centers

28. Issues with statistics Lack of population-based data

29. Issues with statistics Studies have involved small samples and retrospective analysis of data.

30. Misdiagnosis Issues with Statistics

31. Co-Morbidity with Epilepsy Rates of 20 - 60% D'Alessio et al. 2006

32. PNES Statistics Ages as young as 5 years but mostly adolescents

33. PNES Statistics Typically manifest between ages 15 and 35 years. Pediatric study - Mean age of onset 12 years, 9 months (range 5.5 – 19.5) Szabo et al 2012

34. PNES Statistics mostly female among adolescents (age 13 +) 65 - 76% female mostly male among children (age 12 and below) 50 – 66.7% male

35. Presentation • Generalized tonic clonic movements • Focal tremors • Focal clonic movement • Headache or abnormal sensation • Yi et al 2014

36. Dissociative symptoms Dystonia after hyperventilation Atonic features with unresponsiveness Vacant staring with tonic posture Yi et al 2014 Presentation

37. Presentation Older children Motor symptoms Szabo et al 2012

38. Presentation - Duration Typically longer than Epileptic seizures 269 seconds PNES versus 83 seconds epilepsy Szabo et al 2012 Cole et al 2014 Rao, 2012

39. Presentation Gradual and slow onset Gradual offset Cole et al., (2014); Alessi et al., 2014

40. Presentation Lack of rhythmic/synchronic movements Convulsions asynchronous, asymmetric, waxing and waning, accelerating, or decelerating Alessi et al, 2014 Rao, 2012

41. Presentation Pelvic thrusting rare Szabo et al 2012

42. Presentation Inconsistent seizure history Changes in semiology Cole et al., 2014

43. Presentation Tend to occur while awake and in presence of others Cole et al., 2014 ; Weichaital et al., 2015; Rao, 2012

44. Presentation Avoidance/guarding behavior Few injuries sustained as result of seizure Weichaital et al 2015 Rao, 2012

45. Presentation Consciousness generally retained or fluctuates Responsive to verbal requests/suggestions Rao, 2012; Szabo et al 2012

46. Presentation Eyes shut Resistance of others' attempts to open eyelids Pupils react to light If eyes open and mirror placed in front of face will abort seizure Weichaital et al, 2015; Rao, 2012

47. Presentation Can be interrupted by self or others Rao, 2012

48. Presentation Rapid return to baseline Absence of post ictal change or confusion Cole et al., 2014; Rao, 2012; Alessi et al., 2014

49. Co-morbid Psychiatric Diagnoses

50. Co-morbid Psychiatric Diagnoses • Similar to those with epilepsy often have • comorbid psychiatric diagnoses including • depression • anxiety • Salpekar et al., 2009 • Sawchuk & Buchhalter 2015