Multidisciplinary management of psychogenic non-epileptic seizures (dissociative seizures) in children - lessons learnt from an inpatient service experience

Abstract

Introduction: Psychogenic non-epileptic seizures (PNES) present difficulties in diagnosis and management and facilities to manage these children vary greatly. Objectives: This study aimed to evaluate the effect of a multidisciplinary inpatient epilepsy/ neuropsychiatric service in improving outcomes of children with psychogenic non-epileptic seizures. Methods: This retrospective study identifies lessons learnt from managing children with PNES in a specialist inpatient facility in Oxford, United Kingdom over a ten-year period. Forty-two children were identified and categorised into 3 groups: group A (n=21) with one or more epileptic seizures prior to the onset of PNES; group B (n=6) with no epileptic events but interictal EEG showing epileptiform discharge and; group C (n=15) with no prior epileptic events and normal interictal EEGs. All patients received inpatient input for 6-8 weeks from a multidisciplinary team (MDT) led by a neuropsychiatrist and neurophysiologist with special interest in paediatric epilepsy, supported by experienced nurses, psychologists, occupational therapists and hospital schoolteachers. Results: Following initial investigations (including video-telemetry) to exclude organic pathology, a positive diagnosis of PNES was conveyed to the family, followed by several meetings to answer questions and explore non-drug interventions. Psychological therapies involved exploring areas of stress, introducing the 'idea of gain' and helping to develop alternative coping mechanisms. Anticonvulsants were gradually withdrawn in many cases. At discharge, episodes of PNES had stopped in the majority of children (20/21 (95%) in group A, 6/6 (100%) in group B and 12/15 (80%) in group C. Conclusion: In our series, the facility of an inpatient epilepsy/neuropsychiatric service allowed for rapid thorough assessment and subsequent successful management of PNES. Early involvement of an MDT allowed children and their parents the space to accept the diagnosis and move forward.