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Am Fam Physician. 1999;59(11):3161-3162

Pseudoseizures, sometimes known as psychogenic or hysterical seizures, resemble epileptic seizures but are not associated with abnormal cortical electrical discharges. This condition affects children as young as five years of age and is the underlying problem in up to 22 percent of adults who are referred to specialists for treatment of epilepsy. Sophisticated diagnostic testing, such as prolonged video electroencephalographic (EEG) monitoring, has helped differentiate pseudoseizures from true epilepsy. However, little is known about the psychiatric aspects and outcomes in children and adolescents with pseudoseizures. Wyllie and colleagues evaluated these factors in a retrospective review of pediatric and adolescent patients treated for pseudoseizures at the Cleveland Clinic Foundation between 1992 and 1996.

Children between nine and 18 years of age who had a diagnosis of pseudoseizures confirmed by ictal video EEG were eligible for the study. At the time of diagnosis, 70 percent of the patients were taking antiepileptic medication. However, these medications were discontinued in all patients before several days of testing with prolonged video EEG monitoring. During the monitoring period, each patient experienced at least one pseudoseizure that was described by the family and patients as “typical.” EEG readings obtained during seizure activity were consistently normal, except in four children who had a previous and concurrent diagnosis of true epilepsy. After the diagnosis of pseudoseizure was confirmed, a pediatric neurologist immediately presented the results to the patients and family. Anticonvulsant medications were not resumed except in the four children with true epilepsy. All patients were also examined by a pediatric psychiatrist at this time to identify any underlying problems.

Thirty-four children with pseudoseizures were included in the study. Mean patient age was 14 years, and mean duration of pseudoseizures until video diagnosis was about 11 months. All patients had a diagnosis of conversion disorder according to the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria. However, malingering, factitious disorder and factitious disorder by proxy were ruled out in all patients. Moderate to severe psychosocial stressors, such as severe family stress, sexual or physical abuse, and school failure, were identified in 31 patients. From this larger group, two principal subgroups were identified. Eleven patients had major mood disorders and, of these, seven had a history of sexual abuse. Eight patients experienced separation anxiety/school refusal but, in this group, psychosocial stressors were less severe. Patients in the latter subgroup also benefited from family counseling and, in some cases, medical therapy. However, in most patients, pseudo-seizures tended to occur months or even years after a specific psychosocial stressor, such as physical or sexual abuse, or in the context of chronic family dysfunction.

Long-term follow-up was available for only 21 patients. Of these, 15 had had no seizures for nine to 55 months after the initial evaluation. These patients reported that the number of seizures gradually decreased until they were seizure-free, typically within two years. Two of the four children who had both epilepsy and pseudoseizures had no further recurrences but continued to take medication. Because of the small number of patients successfully contacted during follow-up, any analysis of outcomes would be inconclusive, although no clear trends were apparent between subgroups.

The authors conclude that all children and adolescents with suspected pseudoseizures should undergo video EEG and a detailed psychiatric evaluation. Most patients with pseudoseizures also have major mood disorders and severe psychosocial stressors. Specific stressors include parental divorce, death of a family member and sexual and physical abuse. Although it was not proved definitively in this study, the authors suggest that some children benefit from counseling or other mental health interventions, including medical therapy.

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Copyright © 1999 by the American Academy of Family Physicians.

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