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Mental Functions and
Non-Epileptic Seizures in
Children
Robert W. Trobliger, Ph.D.
Co-Director Clinical Neuropsychology
Northeast Regional Epilepsy Group
Non-Epileptic Seizures
versus
Epileptic seizures
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
Prevalence of Epilepsy in the U.S.
• 2.2 million people
• 7.1 for every 1000 people (0.7%)
Epilepsy Foundation
www.epilepsy.com
Prevalence of Diabetes in the U.S.
29.1 million people
9.3%

www.diabetes.org
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
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
Differential Diagnosis
Epileptic Seizures
versus
Paroxsymal Non-epileptic Events (PNEs)
Differential Diagnosis
Ex: Psychogenic Non-epileptic Seizures
(PNES)
versus
 pseudo-seizures
 non-epileptic seizures
 psychogenic seizures
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)
PNEs – Organic Disorders



vascular conditions
movement disorders (Parkinson's,
Huntington's)
gastrointestinal disorders
PNEs - psychiatric
disorders/conditions





ADHD – inattention/daydreaming
PTSD – flashbacks and dissociative episodes
anxiety disorder/panic attacks
conversion disorder (PNES)
malingering
Reilly et al 2013
Psychogenic Non-epileptic Seizures
(PNES)
Paroxysmal events with discernible changes in
behavior or consciousness but with no
accompanying electrophysiologic changes.
Psychogenic Non-epileptic Seizures
(PNES)



Involuntary
time limited
involve
motor,
sensory,
or behavioral occurrences

resemble epileptic seizures.
Psychogenic Non-epileptic Seizures
(PNES)




alteration of consciousness
posturing
jerking of the extremities
sensory or behavioral disturbances
Psychogenic Non-epileptic Seizures
(PNES)
Underlying psychological causes behind the
seizures
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)
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.
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.
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.
Conversion Disorder
Somatic Disorder
Somatization is the process whereby physical
symptoms are experienced in response to
stress.
PNES Statistics
5 - 20% of adults in outpatient epilepsy
population
PNES Statistics
Some questions regarding underestimating
most numbers come from neurology/epilepsy
centers, with VEEG studies.
PNES Statistics
20 - 40% children evaluated in epilepsy clinics
reported to have PNES
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
Issues with statistics
Difficult to establish estimates of prevalence or
incidence of PNES in childhood.
Issues with statistics
Question if widely diagnosed outside of epilepsy
centers
Issues with statistics
Lack of population-based data
Issues with statistics
Studies have involved small samples and
retrospective analysis of data.
Issues with Statistics
Misdiagnosis
Co-Morbidity with Epilepsy
Rates of 20 - 60%
D'Alessio et al. 2006
PNES Statistics
Ages as young as 5 years but mostly adolescents
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
PNES Statistics
mostly female among adolescents (age 13 +)
65 - 76% female
mostly male among children (age 12 and below)
50 – 66.7% male
Presentation
•
•
•
•
Generalized tonic clonic movements
Focal tremors
Focal clonic movement
Headache or abnormal sensation
Yi et al 2014
Presentation
Dissociative symptoms
 Dystonia after hyperventilation
 Atonic features with unresponsiveness
 Vacant staring with tonic posture

Yi et al 2014
Presentation
Older children
Motor symptoms
Szabo et al 2012
Presentation - Duration
Typically longer than Epileptic seizures
269 seconds PNES
versus
83 seconds epilepsy
Szabo et al 2012
Cole et al 2014
Rao, 2012
Presentation
Gradual and slow onset
Gradual offset
Cole et al., (2014); Alessi et al., 2014
Presentation
Lack of rhythmic/synchronic movements
Convulsions asynchronous, asymmetric, waxing
and waning, accelerating, or decelerating
Alessi et al, 2014
Rao, 2012
Presentation
Pelvic thrusting rare
Szabo et al 2012
Presentation
Inconsistent seizure history
Changes in semiology
Cole et al., 2014
Presentation
Tend to occur while awake and
in presence of others
Cole et al., 2014 ; Weichaital et al., 2015; Rao, 2012
Presentation
Avoidance/guarding behavior
Few injuries sustained as result of seizure
Weichaital et al 2015
Rao, 2012
Presentation
Consciousness generally retained or fluctuates
Responsive to verbal requests/suggestions
Rao, 2012; Szabo et al 2012
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
Presentation
Can be interrupted by self or others
Rao, 2012
Presentation
Rapid return to baseline
Absence of post ictal change or confusion
Cole et al., 2014; Rao, 2012; Alessi et al., 2014
Co-morbid Psychiatric Diagnoses
Co-morbid Psychiatric Diagnoses
Similar to those with epilepsy often have
comorbid psychiatric diagnoses including
depression
anxiety
Salpekar et al., 2009
Sawchuk & Buchhalter 2015
Co-morbid Psychiatric Diagnoses
No significant difference between PNES and
epilepsy groups of children regarding
psychopathology on the CBCL – but both had
more than controls.
Chinta et al, 2008
Co-morbid Psychiatric Diagnoses
Other diagnoses
•
•
•
•
Depression
Anxiety
Behavioral problems
ADHD
Szabo et al 2012
Co-morbid Psychiatric Diagnoses
Wyllie et al 1999
• Psychiatric diagnoses DSM IV
• Axis 1
• Major depression
• Panic disorder
• Bipolar disorder, depressed
• Dysthymic disorder
Co-morbid Psychiatric Diagnoses
•
•
•
•
•
Post Traumatic Stress Disorder (PTSD)
Brief reactive psychosis
Schizophreniform disorder
Separation anxiety/school refusal
Attention Deficit Hyperactivity Disorder
(ADHD)
Co-morbid Psychiatric Diagnoses
• Overanxious disorder
• Adjustment disorder with mixed emotional
features
• Oppositional Defiant Disorder
• Impulse control disorder
Co-morbid Psychiatric Diagnoses
• Axis II
• Mild mental retardation (Intellectual
Disability)
• Dependent traits
• Borderline personality disorder
• Mixed personality disorder
• Histrionic personality disorder
Co-morbid Psychiatric Diagnoses
• Axis III
Epilepsy
Febrile seizures
Head trauma
Hearing impairment
Framework
Similar to epilepsy in terms of presentation but
caused by psychological processes
Framework
Usually understood as reflecting underlying
psychological distress
Framework
Dysfunction in processing of
psychosocial stress
Baslet 2012
Framework
Associated with a number of traits
dissociative tendencies
alexithymia
cognitive inflexibility
hypervigilance
Baslet 2012
Factors
• For 93% of patients there was a significant life
stressor
• Of those, 76% were determined to be chronic
Sawchik & Buchhalter 2015
Factors
In most, the seizures did not immediately follow
a specific psychosocial stressor but instead
occurred months or years after sexual or
physical abuse or against the backdrop of
chronic family dysfunction
Wyllie et al 1999
Most Common Factors
School Related Difficulties
Reilly et al 2013
Rawat et al, 2015
Sawchik & Buchhalter 2015
Patel et al 2007
Wyllie et al 1999
Most Common Factors
Interpersonal/Relationship Problems
Reilly et al 2013
Rawat et al, 2015
Patel et al 2007
Sawchik & Buchhalter 2015
Most Common Factors
Family stressors
Rawat et al 2015
Sawchik & Buchhalter 2015
Patel et al 2007
Wyllie et al 1999
Most Common Factors
Physical/Sexual Abuse
- physical abuse most predominant
- sexual abuse only 5%
Reilly et al 2013
Patel et al 2007
Wyllie et al 1999
Most Common Factors
History of sexual abuse among children with
PNES - 15 - 35%
versus
History of physical/sexual abuse among adults
with PNES - 25 - 45%
School factors





learning difficulties
poor performance
stress regarding school work
difficulty adjusting to changes in routine
behavioral problems – detention, suspension
School factors




bullying/assault
fear of examinations
fear of (social) rejection
need for attention
Patel et al., 2007
Reilly et al., 2013
Yi et al (2014)
Family





divorce/separation
parental or sibling relationship problems
domestic physical abuse
financial stress
relative in jail
Family


bereavement
family Illness
Yi et al 2014
Patel et al 2007
Family
Stressful environment often not directly related
to child but affecting subjective perception of
well-being
Interpersonal conflicts – Other

conflicts with peers/friends
Patel et al. 2007
Abuse



emotional abuse
physical abuse
sexual abuse
Patel et al., 2007
Associated Traits
Personality Traits



inhibited
submissive
introverted
Sawchuk & Buchhalter 2015
Personality Traits
consistent with increased passive/avoidant
coping strategy use
Sawchuk & Buchhalter 2015
Coping
More passive coping styles



solitary yelling
hitting
crying
Plioplys et al., 2014
Diagnosis
Diagnosis

comprehensive description of seizures

comprehensive medical/developmental history

and
Diagnosis
VEEG results

no EEG changes during events

no post-ictal slowing on EEG

and
Diagnosis
Possibly supplementary diagnostic tests



MRI (rule out brain tumors)
ECG (rule out heart disease)
blood tests (rule out endocrinologic conditions
such as hypoglycemia)
Diagnosis - VEEG
• International League Against Epilepsy (ILAE)
has suggested that VEEG for correlation with
captured PNES events in combination with
consistent history and semiology as the gold
standard for diagnosis
Diagnosis - VEEG
May take time for episodes to occur during
VEEG, which is relatively peaceful and non
demanding.
Cole et al, 2014
Diagnosis – VEEG
Periodic issues regarding access to VEEG
including insurance clearance or actual physical
access to such
Diagnosis - VEEG
PNES not just a default diagnosis based on VEEG
results, need to show evidence of underlying
conversion disorder by history and evaluation
Plioplys et al 2007
Diagnosis
Comprehensive neuropsychological evaluation
Utility of NP Evaluation
aid diagnosis
elaboration/exploration of history and factors
(given parent/child underreporting, denial, lack of
awareness)

aid treatment
identification of coping strategies

Cole et al 2014
Utility of NP Evaluation
Provide recommendations for school
accommodations which can be addressed
through an IEP (covered under the ADA, IDEA)

Cole et al 2014
NP - Interview
Exploration of family functioning/dysfunction



inter-relationships
impact of separation/divorce/conflict
bereavement
NP - Interview
Exploration of psychological factors






anxiety/stress
depression
history of sexual abuse
history of physical abuse
history of emotional abuse
history of psychological trauma
Diagnostic Issues
Common for more information to come out
during interview – particularly when child and
parents interviewed separately
Diagnostic issues
Children and parents often deny the presence of
any problems other than seizures.
Cole et al, 2014
Diagnostic Issues
Sometimes a lack of awareness
Diagnostic Issues
Common for issues to come up during
feedback , possibly in reaction to findings from
neuropsychological evaluation
NP Evaluation
Comprehensive
• Cognitive functioning
• Academic functioning
• Psychological functioning – parent, child
reports
Treatment
Treatment
Early acceptance of the diagnosis is important
for pediatric and adult outcomes
Sawhcuk & Buchhalter 2015
Treatment

effective and sensitive communication of
diagnosis

presenting episodes as real – not faking

emphasizing psychological basis
Treatment

diagnosis given separately

avoid misinterpretation by parents

address parental feelings of guilt
Cole et al 2014
Treatment


referral for therapy
referral for psychiatric evaluation to determine
if psychotropic medication necessary
• Symptoms may undergo spontaneous
resolution following explanation and
suggestion
• PNES is treated by mental health providers,
but continued involvement of neurologists is
recommended.
Cole et al 2014
• Follow up with neurologist during transition to
aid process, but also to ensure that no
epileptic seizures have been missed
Continued use of AEDS

Most neurologists discontinue AEDs soon
after diagnosis
Cole et al 2014
Effects of continued use of AEDs


impact cognitive functioning
behavioral and mood side effects such as
irritability and mood instability
These reasons should be explored with the
family and addressed.
Cole et al 2014
• Treatment – Cognitive Behavioral Approach
Emphasizing relationships between:



mood
cognition
environment
Identification of:



moods
situations
thoughts
Identification and examination of:
internal triggers
external triggers
Relaxation techniques
Treatment Issues
Treatment Issues
Wichaidit et al 2015 study of Danish pediatricians Dan–
found that ER visits without follow up were seen
never by 70%
rarely by 25%
and
sometimes by 5%
Which suggests that some do not follow up on the
diagnosis.
Treatment Issues
Many mental health providers may be
uncomfortable with treatment due to
unfamiliarity with the diagnosis, concern about
how to handle seizures – which raises concerns
about where to refer
Cole et al 2014
Treatment Issues
misdiagnosis and diagnostic delay for several
years are common.
Wichaidit et al 2015
Treatment Issues
It is unknown how many adult sufferers of PNES
first had symptoms onset in childhood.
Sawchuk & Buchhalter 2015
Costs of mistaken/delayed
diagnosis
Costs of mistaken/delayed diagnosis
financial considerations
 medications
 tests
 unnecessary investigations
Sawchuk & Buchhalter 2015
Costs of mistaken/delayed diagnosis
impact on school/social functioning –
absenteeism
Sawchuk & Buchhalter 2015
Costs of mistaken/delayed diagnosis
delay for appropriate treatment
Sawchuk & Buchhalter 2015
Costs of mistaken/delayed diagnosis
impact of medication on cognitive
functioning
Sawchuk & Buchhalter 2015
Prognosis
Prognosis
Even patients with severe psychopathology can
improve
Yi et al, 2014
Prognosis
review of follow up studies
• 18-72% seizure free
• 20-47% improvement
• 0-18 no improvement
Reilly et al 2013
Prognosis
Yi et al, 2014 found 80% had remission
Similar to another pediatric study of 78%
at 30 months follow-up
Prognosis
Rawat et al (2015) follow up (mean 10.1
months)

76.5% no PNES episodes

14.7% reduced number

8.8% same or increased frequency
Prognosis
of those who underwent therapy:



60% responded well with no episodes
20% had partial response with reduced
frequency
20% had continued – same or increased
frequency
Prognosis
Combination of therapy/medication (SSRIs)
88.9% showed improvement, with partial or
complete resolution
Rawat et al (2015)
Prognosis
Sawchuk & Buchhalter 2015



59% complete event remission by
conclusion of treatment
21% partial remission - more than 50%
reduction in frequency
7% refractory to treatment
Prognosis
1 person had a single assessment session and
a single session of feedback, with full
remission following
Prognosis
Among patients with no improvement with
therapy and their families, there was no
acceptance of the diagnosis
Treatment
Goldsten et al 2010
CBT plus standard medical care produced
greater reduction in seizure frequency
than standard medical care
Monthly seizure frequency from start to end
CBT/SMC 12 to 2
SMC 8 to 6.75
Conclusions
Typical factors involve
•
•
•
•
Family dynamics
Social dynamics
School dynamics
Abuse
Conclusions
Chronic stressors
Conclusions
Diagnosis

VEEG monitoring
exploration of medical and psychological
history – through interview and evaluation

Conclusions
This information is gathered through
multiple sources –

interview with patient and family

review of records

NP testing
Conclusions
Correct diagnosis and referral can

save resources

alleviate significant distress

stop unnecessary treatment

begin appropriate treatment
Conclusions
good prognosis provided:

diagnosis made early and sensitively

cause identified

appropriate intervention
Conclusions
Encouraging treatment improvement rates
with:

acceptance of diagnosis

appropriate treatment
End
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