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Psychogenic non-epileptic seizures

Article  in  Indian pediatrics · November 2004

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CASE REPORTS

of choice. If heart failure persists even after lupus erythematosu in a newborn infant. Arch
pacemaker implantation and children who Dermatol Syph 1954; 70: 781-785.
have serious internal systemic manifestations, 2. Lee LA Frank MB, Victoria R, McCubins
may be treated with systemic steroid(2,3). As Reichlin M. Auto antibodies of Neonatal
many as 8.3% cases of NLE may progress to Lupus Erythematosus. J Invest Dermatol 1994;
systemic lupus erythematosus (SLE) in later 102: 963-966.
childhood(6). 3. Lee LA, Neonatal Lupus Erythromatosus.
J Invest Dermatol 1993; 100: 9S- 13S.
Acknowledgement
4. Crowley E, Frieden IJ, Neonatal lupus
We thank Dr. Sharmila Mishra, Depart- erythematosus: An unusual congenital
ment of Pathology, ICMR, Delhi for review- presentation with cutaneous atrophy, erosions,
ing the skin biopsy. alopecia and pancytopenia. Pediatr Dermatol
1998; 15: 38-42.
Contributors: NA, PP worked up the case, reviewed
the literature and drafted the article. RM planned the 5. Maynard B, Leiferman KM, Peters MS.
management; PP will act as the guarantor. Neonatal lupus erythematosus Syndrome.
J Cutan Pathol 1991: 18: 333-338.
Funding: None
6. Jenkins RE, Kurwa AR, Atherton DJ, Black
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MM. Neonatal lupus erythematosus. Clin and
1. McCuiston CH, Schoch Jr EP. Possible discoid Exp Dermatol1994; 19: 409-411.

Psychogenic Non-Epileptic diagnosis of epileptic seizures. We report two

children with features suggestive of epileptic seizures
Seizures that were eventually diagnosed as PNES with the help
of video-EEG monitoring.
S. Kumar Key words: Epilepsy, Psychogenic non-epileptic
seizures.
Psychogenic non-epileptic seizures (PNES) need
to be differentiated from epileptic seizures as the Psychogenic non-epileptic seizures
management varies for both. Presence of tongue
(PNES) are usually differentiated from
biting, falling and urinary incontinence favors a
epileptic seizures on the basis of absence of
From the Neurology Unit, Department of Neurological tongue biting, falling, incontinence, post-ictal
Sciences, Christian Medical College Hospital, phenomena and concomitant abnormalities on
Vellore, Tamilnadu- 632 004, India. the electroencephalogram (EEG)(1,2). It is
Correspondence to: Dr. Sudhir Kumar, Consultant important to make an early diagnosis of PNES
Neurologist, Department of Neurological Sciences, as a delay in diagnosis leads to overtreat-
Christian Medical College Hospital, Vellore,
Tamilnadu, India-632 004.
ment including polytherapy, repeated
E-mail: [email protected] hospitalization, poor response to treatment,
Manuscript received: January 21, 2004;
and mechanical ventilation(3,4). However,
Initial review completed: February 27, 2004. PNES are frequently misdiagnosed as
Revision accepted: March 24, 2004. epileptic seizures and delays in diagnosis are

INDIAN PEDIATRICS 1050 VOLUME 41__OCTOBER 17, 2004

CASE REPORTS

common(1). This is mainly due to the duration. During the attacks, the child would
presence of clinical features thought to be gradually slump to the ground and start violent
typical of epileptic seizures among those with jerking of hands and legs with thrusting
PNES. movements. He would also produce bizarre
incomprehensible sounds. These would
Case Reports persist for 15-20 minutes and would occur 2-3
Case 1: A 12-year-old child was brought with times per week. Birth and development were
repeated episodes of “seizures” of four years normal. He was studying in second standard
duration. The episodes were characterized by and was doing well in studies. There was no
tonic-clonic movements of all four limbs family history of seizures. Neurological
associated with blinking of eyes. The child examination was normal. MRI of the brain
was “unresponsive” and had urinary and EEG were normal. He was referred to us
incontinence during each of the episodes. as “seizures” were uncontrolled on maximum
There was no history of tongue biting, falling therapeutic doses of sodium valproate and
or sustaining injuries. The child had 8-10 lamotrigine. Episodes were witnessed during
episodes per day and there were no episodes video-EEG monitoring and they were
during nights. Though majority of episodes suggestive of non-epileptic seizures as the
occurred in front of others, a few occurred child would avoid all possibilities of getting
when none was around. He was previously hurt and he would hold his hands in air if they
treated with various antiepileptic drugs and were lifted and let drop by the examiner.
was on maximum therapeutic doses of Further questioning of parents revealed that
phenytoin, carbamazepine and clobazam at the child suffered from chronic constipation
presentation. Clinical examination was and would pass stools once in 7-10 days.
normal. MRI scan of the brain and EEG were Extensive investigations by gastroentero-
normal. Video-EEG monitoring showed that logists for the same were normal. At this stage,
the child’s attacks were non-epileptic in origin psychiatrist saw him and it was found that the
as during the attacks, he would stand up and child felt extremely embarrassed to go to toilet
jerk his limbs in a bizarre fashion and pass and pass stools, especially in school. He learnt
urine. He would maintain eye contact but to habitually constipate himself. The urge to
would not answer questions. The episode pass stools were constantly suppressed and
would last for about 5-30 minutes and resulted in NES. He was adequately counseled
concomitant EEG recording was normal and showed a marked improvement in
except for movement artifacts. A psychiatric frequency of attacks.
evaluation revealed the presence of learning Discussion
disability and over-expectation from parents.
Both parents and the child were counseled and Psychogenic nonepileptic seizures
antiepileptic drugs were gradually withdrawn. (PNES) are episodes of altered movement,
The child became seizure-free four weeks sensation, or experience similar to those due
after starting treatment and remains well at the to epilepsy but caused by a psychogenic
last follow up after two years. process and not associated with abnormal
electrical discharges in the brain(5).
Case 2: A seven-year-old boy presented with “Pseudoseizures” as a term is better avoided
episodic jerking movements of limbs as it attempts to deny the validity of the events
associated with unresponsiveness of two-year altogether. PNES are common in children and

INDIAN PEDIATRICS 1051 VOLUME 41__OCTOBER 17, 2004

 CASE REPORTS

adolescents. The prevalence of PNES has to the child, more easily identified, and more
been estimated to be between 2-33 per amenable to prompt intervention(11).
100, 000 population(6). Moreover, about 25% Funding: None.
of neurologically normal patients and upto Competing interests: None.
60% of children with mental retardation
referred for evaluation of seizures have REFERENCES
PNES(7). PNES also accounts for about 20% 1. de Timary P, Fouchet P, Sylin M, Indriets JP,
of cases referred for evaluation of refractory de Barsy T, Lefebvre A, et al. Non-epileptic
epilepsy(8). seizures: delayed diagnosis in patients
presenting with electroencephalographic
Although PNES are common, a significant (EEG) or clinical signs of epileptic seizures.
delay often occurs prior to their diagnosis. The Seizure 2002; 11:193-197.
mean time-lapse between the first attack and 2. Tamer SK. The pediatric non-epileptic seizure.
PNES diagnosis has been found to range from Indian J Pediatr 1997; 64:671-676.
7.2 years(9) to 8.7 years(1). In our cases, the 3. Tuxhorn IE, Fischbach HS. Pseudostatus
diagnosis was made after a delay of four and epilepticus in childhood. Pediatr Neurol 2002;
two years respectively. The reasons for a 27: 407-409.
delayed diagnosis are manifold. Presence of
4. Holmes GL. Overtreatment in children with
clinical signs typically associated with epilepsy. Epilepsy Res 2002; 52: 35-42.
epileptic seizures (such as tongue biting,
5. Lesser RP. Psychogenic seizures. Neurology .
falling, incontinence) is thought to be against
1996; 46: 1499-1507.
a diagnosis of PNES. However, in a recent
study(1), at least one of these signs was 6. Benbadis SR, Allen Hauser W. An estimate of
the prevalence of psychogenic non-epileptic
reported by 66% of patients finally diagnosed
seizures. Seizure 2000; 9: 280-281.
to have PNES. One of our patients too had
urinary incontinence during most of the 7. Paolicchi JM. The spectrum of nonepileptic
attacks. Interictal EEG abnormality is also events in children. Epilepsia 2002; 43 Suppl 3:
60-64.
thought to be a factor supporting a diagnosis
of epilepsy; however, about 16% of patients 8. Wada JA. Differential diagnosis of epilepsy.
finally diagnosed to have PNES had interictal Electroencephalogr Clin Neurophysiol Suppl
1985; 37: 285-311.
EEG abnormalities(1). Delayed diagnosis of
PNES hampers child’s education and poses an 9. Reuber M, Fernandez G, Bauer J,
undue economic burden on families. A Helmstaedter C, Elger CE. Diagnostic delay
in psychogenic nonepileptic seizures.
diagnosis of PNES should be suspected in
Neurology 2002; 58: 493-495.
children with uncontrolled seizures, atypical
clinical presentation, learning disability, 10. Bhatia M, Sinha PK, Jain S, Padma MV,
Maheshwari MC. Usefulness of short-term
mental retardation and history of physical or
video EEG recording with saline induction in
sexual abuse. Video-EEG monitoring is pseudoseizures. Acta Neurol Scand 1997; 95:
extremely useful in making an early 363-366.
diagnosis(10). An encouraging point to note is
11. Irwin K, Edwards M, Robinson R.
that the outcome of children with PNES after Psychogenic non-epileptic seizures: manage-
treatment is better than that of adults, perhaps ment and prognosis. Arch Dis Child 2000; 82:
because causes are more likely to be external 474-478.

INDIAN PEDIATRICS 1052 VOLUME 41__OCTOBER 17, 2004

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