title: Psychogenic nonepileptic seizures in children - Psychological presentation, treatment, and short-term outcomes.
abstract: OBJECTIVE
  The purpose of this study was to better understand the etiologies, features, and care outcomes of psychogenic nonepileptic seizures (PNESs) in a pediatric setting.
  
  
  METHODS
  We performed a retrospective analysis of 32 sequentially referred children for suspected PNESs to a neurology psychology service over a 6-year period. After excluding non-PNES paroxysmal events (related to anxiety or migraine), 29 patients were identified with final diagnosis of PNESs. Charts were examined for presenting symptom data, demographics, comorbidities, neurological diagnoses and investigations, as well as psychological assessment, management, and outcome. Treatment consisted of education around diagnosis and of individual psychological treatment, which, in most cases, was cognitive behavioral therapy up to 14 sessions. Additional mental health services including psychiatric medication, family therapy, and admission to day or inpatient treatment were also utilized in a smaller number of cases. Total treatment periods ranged from 4 weeks to 12 months.
  
  
  RESULTS
  The majority of patients identified were adolescent (90%), Caucasian (72%), and female (76%). Preceding psychology referral, point of entry into medical care for PNESs was primarily through the emergency department (66%) or outpatient neurology clinic referral (31%). Whereas 39% of parents described significant internalizing symptoms in their child (BASC-2), patients themselves tended to underreport anxiety or depression as demonstrated by only 16% endorsement on the BYI-II. By contrast, MACI personality assessment response patterns for adolescents demonstrated high levels of psychic tension/anxiety (65%), depressive affect (55%), and maladaptive personality traits including inhibition (45%), submissiveness (35%), and introversion (30%). Appropriate psychological treatment was associated with high rates of full remission (no new events, n=17, 59%) and partial remission (50% or greater reduction in events, n=6, 21%) as self-reported at discharge. Accurate diagnosis and referral to psychology also led to a sevenfold reduction in PNES-related emergency department visits one year after initial psychology visit compared with the preceding year.
  
  
  CONCLUSIONS
  This study suggests that appropriate care for PNESs reduces inappropriate medical investigation and therapy, expedites rates of remission, and decreases health-care utilization in a pediatric setting.
authors.affiliation: Alberta Children's Hospital, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada. Electronic address: tyson.sawchuk@albertahealthservices.ca.
authors.forename: Tyson
authors.initials: T
authors.lastname: Sawchuk
authors.affiliation: Alberta Children's Hospital, Calgary, AB, Canada; Alberta Children's Hospital Research Institute, Calgary, AB, Canada; University of Calgary, Cumming School of Medicine, Department of Pediatrics, Canada; University of Calgary, Cumming School of Medicine, Department of Clinical Neurosciences, Canada.
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Buchhalter
mesh_terms: D000293:Adolescent; D001007:Anxiety / Q000523:psychology; D002648:Child; D003863:Depression / Q000523:psychology; D004632:Emergency Medical Services; D005196:Family Therapy; D005260:Female; D006801:Humans; D008297:Male; D010551:Personality; D010556:Personality Tests; D011613:Psychotherapy; D012017:Referral and Consultation; D012189:Retrospective Studies; D012640:Seizures / Q000175:diagnosis / Q000523:psychology* / Q000628:therapy*; D012959:Socioeconomic Factors; D013001:Somatoform Disorders / Q000175:diagnosis / Q000523:psychology / Q000628:therapy*; D016896:Treatment Outcome
keywords: Children; Dissociative seizure; Epilepsy; Millon Adolescent Clinical Inventory; Nonepileptic event; PNESs; Pseudoseizure