Pseudoseizure manifestations in two preschool age children

Staring Spells: How to Distinguish Epileptic Seizures from Nonepileptic Staring

OBJECTIVE

To determine the nature of staring spells and factors distinguishing epileptic from nonepileptic staring spells, we studied the clinical and demographic features of children with staring spells referred to a regional new-onset seizure clinic.

STUDY DESIGN

Our retrospective chart review encompassed 2818 consecutive patients evaluated in the new-onset seizure clinic between September 22, 2015, and March 19, 2018. We identified 121 patients with newly presenting staring spells.

RESULTS

Sixty-two of 121 (51%) children were diagnosed with nonepileptic staring spells and 59 (49%) with epileptic seizures (24 with absence epilepsy, 35 with focal epilepsy). Patients with nonepileptic staring spells were younger (4.8 vs 7.1 years, P = .001) and more likely to have developmental delay (P = .005) than the seizure group. There was an 8.9-month delay on average from the onset of staring spells to the new-onset seizure clinic visit. The emergency department was a referral source for 80% (28/35) of focal seizures. In children with focal seizures, the staring spells typically lasted >1minute (29/35, 83%), whereas only 19 of 62 (31%) of children with nonepileptic staring spells had events lasting this long (P = .04). All children had a routine electroencephalography (EEG) on the day of new-onset seizure clinic visit. EEG was diagnostic in 100% (24/24) of absence seizures and 51% (18/35) of focal seizures.

CONCLUSIONS

In children presenting with staring spells, the differential diagnosis of epileptic staring spells vs nonepileptic staring spells can be made by history and routine EEG. Staring was as likely to be epileptic as nonepileptic spells. Younger children with developmental delay were more likely to have nonepileptic events. Our simple approach based on event duration, postictal symptoms, and EEG allowed identification of epileptic staring on first visit to new-onset seizure clinic but requires validation in future prospective studies including long-term video EEG monitoring and follow-up.

Treating Pseudoseizures and Related Behaviors in an Adult Male with an Intractable Seizure Disorder

AD, a 42-year-old male diagnosed with an intractable seizure disorder, profound mental retardation, and numerous medical diagnoses, manifested pseudoseizures and related behaviors. To reduce the frequency of these behaviors, treatment procedures were developed and implemented. In conjunction with direct care staff members, target behaviors were identified and defined: pseudoseizures, falling, and sliding from chair. The behavioral treatment applied combined antecedent control and a progressive intervention approach using verbal cueing, visually checking, tactile attention, and edible reinforcement. Data collection occurred over an 18-month period. Results show an increase in the number of days occurring without charted behaviors within consecutive 28-day reporting periods. Data collection consisted of 7,068 observations of AD's behaviors. This allowed correlations to be conducted with significant correlations existing between pseudoseizures and falling ( r = .59) and chair sliding and positive observations ( r = —.63). t tests were computed resulting in significant differences between AD's target behaviors and pseudoseizures.

Hypnosis-provoked nonepileptic events in children

OBJECTIVE

The purpose of this study was to describe the use of hypnotic suggestion as a means of precipitating nonepileptic events in children while they are undergoing video electroencephalographic monitoring (VEEG) for differential diagnosis of seizurelike behavior.

METHODS

Nine children aged 8-16 years were referred for VEEG to differentiate between epileptic seizures and nonepileptic events. All subjects underwent psychiatric consultation. Hypnosis was attempted in all subjects to try to provoke typical seizurelike events.

RESULTS

In eight of nine patients, their typical seizurelike events were provoked by hypnosis. In all eight children, video and EEG analysis of the provoked events demonstrated them to be nonepileptic. No epileptiform abnormalities were present on interictal EEGs. No epileptic seizures occurred.

CONCLUSION

Hypnosis is a useful and ethical means of provoking psychogenic nonepileptic events in children. Hypnotic suggestion should be considered as a provocative method when possibly psychogenic nonepileptic events have not occurred spontaneously during diagnostic evaluation.

Psychogenic status epilepticus in children

Epilepsy features, psychiatric profile, psychosocial factors, and outcome are described for six children (three males) aged 5-15 years (mean 12.1) with psychogenic status epilepticus (PSE), i.e., prolonged or repetitive psychogenic seizures (PSs), >30 minutes, simulating status epilepticus. They had epilepsy, they were on chronic anticonvulsants (ACVs), and some had other neurological deficits. All received intravenous and/or rectal ACVs prior to suspicion of PSE. PSE was confirmed via video/EEG, demonstrating no epileptogenic activity during alleged seizures. Provocation and placebo therapy techniques were used in two. Psychiatric assessment identified comorbid disorders such as depression, anxiety disorder, obsessive-compulsive disorder, obsessive-compulsive symptoms, and posttraumatic stress disorder. Psychosocial stressors were almost ubiquitous. Psychiatric intervention included psychotherapy, family therapy, and medical treatment in one patient. Outcome was monitored for an average of 3.6 years (3-5 years). PSE did not recur. PSs recurred in three. Psychiatric comorbidity improved in four, who accepted psychiatric intervention and whose epilepsy also improved. In conclusion, the occurrence of PSE in children and adolescents with epilepsy is stressed. Prompt diagnosis was often missed in the acute care setting, and this carries important implications for iatrogenic complications. PSE diagnosis resulted in identification and management of comorbid psychiatric disorders. This was probably important in reducing the predominating anxiety and affective disorders in most patients as well as PSE recurrence. Epilepsy severity and associated deficits were most likely important factors in determining outcome.

Pseudostatus epilepticus in childhood

Pseudostatus epilepticus in childhood has not been well reported in the literature. We describe the clinical presentation and management of a 9-year-old child with well-controlled epilepsy who presented in a prolonged period of pseudoseizures. Intensive care management over a number of weeks with multiple high-dose antiepileptic drugs, anesthesia, and ventilation at a tertiary care pediatric center was performed before the diagnosis of pseudostatus epilepticus was made. Initiation of family counseling and behavior therapy after diagnosis of the nonepileptic nature of the protracted paroxysmal events with video telemetry in our pediatric epilepsy unit was followed by remission. The patient reported herein illustrates the risks of iatrogenic morbidity that may result from a delay in the diagnosis of pseudoseizures and pseudostatus epilepticus in childhood.

Paroxysmal nonepileptic events in children and adolescents

OBJECTIVE

Paroxysmal nonepileptic events (PNEs) are frequently encountered in children and adolescents; however, there is little information concerning the relative frequency of various types of these disorders. We report our experience with PNEs in a group of children and adolescents who underwent prolonged video-electroencephalographic monitoring.

METHODS

During a 6-year period, 883 patients were monitored in the Pediatric Epilepsy Monitoring Unit and 134 patients (15.2%) were documented to have PNEs on the basis of a typical spell recorded during monitoring. Their hospital charts were reviewed and videotapes of these events were analyzed.

RESULTS

Patients were divided into 3 age groups: 1) the Infant, Toddler, and Preschool Group (2 months-5 years) that comprised 26 patients. The most common diagnoses were stereotyped movements, hypnic jerks, parasomnias, and Sandifer syndrome. Concomitant epilepsy was present in 12 patients (46%). 2) The School-Age Group (5-12 years) consisted of 61 patients. The most frequent diagnoses were conversion disorder (psychogenic seizures), inattention or daydreaming, stereotyped movements, hypnic jerks, and paroxysmal movement disorders. Fifteen patients (25%) had concomitant epilepsy. 3) The Adolescent Group (12-18 years) consisted of 48 patients, of whom 40 patients (83%) were diagnosed with conversion disorder. Nine patients (19%) had concomitant epilepsy.

CONCLUSIONS

In our patients with PNEs, conversion disorder was seen in children >5 years old and its frequency increased with age, becoming the most common type of PNEs among adolescents. In adolescents, conversion disorder was more common in females, whereas males predominated in the school-aged group. Concomitant epilepsy with nonepileptic events occurred in all 3 age groups to a varying extent.

Hypnosis provoked pseudoseizures: a case report and literature review

Only a few studies have been reported in which suggestion was used to provoke pseudoseizures (PS). In these studies PS were video EEG monitored, and saline injections were administered as placebo. This method may be somewhat unethical and carries a low success rate. The authors, two child psychiatrists (GZ and DS) and a neurologist (NG), applied hypnosis to provoke PS which were monitored by video-EEG. Pre-, intra- and post-ictal serum prolactin levels were determined. The first hypnotic session was diagnostic and for this reason featured controlled attempts to determine whether there might be childhood trauma material. The following sessions easily provoked PS during which the EEG was normal and pre-, intra- and post-ictal serum prolactin levels were identical and within normal values. We conclude that hypnosis (with informed consent) for PS monitored by video-EEG telemetry, seems to be an ethical, cheap and quite easy way to demonstrate PS.

Differential diagnosis of staring spells in children: a video-EEG study

Staring is frequently a nonepileptic manifestation in children. To differentiate epileptic versus nonepileptic staring, we reviewed clinical and video-EEG findings in 143 patients, aged 5 months to 43 years, monitored for staring episodes. In 79 patients staring was of epileptic origin; 46 had partial seizures and 33 atypical absence. Thirty-five had behavioral staring, 8 psychogenic seizures, 1 a migraine equivalent, and in 20 no staring spells were recorded. In all patients with epileptic staring, epilepsy was suspected clinically. Only 22 of the admissions for behavioral staring and 3 for pseudoseizures were to exclude a possible nonepileptic phenomenon. Review of their clinical histories revealed that certain findings strongly support a nonepileptic origin. In conclusion, a careful clinical history will differentiate between epileptic and nonepileptic staring episodes in most patients. Video-monitoring is helpful to adjust treatment or to exclude nonepileptic events in patients with refractory staring spells.