(PO-115) Newly diagnosed psychogenic non-epileptic seizures in the context of chronic pain: Addressing challenges in management and review of literature
Functional neurological disorders (FND) are complex biopsychosocial disorders with a prevalence between 0.5-10% in pediatric patients (Doss, 2017). FND includes psychogenic nonepileptic seizures (PNES), which comprise up to 25% of all patients admitted to inpatient epilepsy monitoring units (Doss, 2017). Furthermore, literature shows that PNES cases are significantly associated with chronic pain syndromes (Gazzola, 2012). Anticipating the potential challenges in discussing diagnosis with families and coordinating care across multiple specialties is critical in providing empathic, appropriate, and cost-effective care. We present a challenging case of an individual with newly diagnosed PNES complicated by concurrent pain and review of literature on the management of PNES.
Mr. Z is a 16-year-old male with no psychiatric history and past medical history of pelvic floor instability. He presented to the hospital for constipation and abdominal pain, found to have PNES that involved violent thrashing and reports of intense pain. Multiple teams (physical medicine and rehabilitation, neurology, gastroenterology, psychiatry, physical therapy, anesthesia/acute pain, child life, social work, nursing, hospitalist) collaborated on a multidisciplinary approach to diagnose and treat this patient over several weeks. The episodes decreased in intensity and frequency. He was discharged with a SSRI, outpatient follow-up (pain specialist, psychiatry, and cognitive behavioral therapy), and medical equipment to ensure the patient’s safety at home.
The literature has shown that individuals with PNES also have somatic comorbidities, such as asthma, gastroesophageal reflux, head injuries, and pain (Elliot 2014). The existing guidance on treating these individuals is limited and focuses on the long-term treatments of FND with chronic pain (Tsui, 2017). Our case highlighted the specific challenges that a CL psychiatrist faces in the initial management of PNES with pain. Throughout the hospitalization, the tightly coordinated efforts of the multiple specialties consulted were paramount in establishing the diagnosis, discussing the diagnosis with the patient and family, managing episodes of PNES complicated by pain, and planning post-discharge care.
CL psychiatrists play an important role in the comprehensive multidisciplinary management of individuals with PNES, especially when complicated by somatic comorbidities such as chronic pain.
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Identify potential challenges to managing newly diagnosed psychogenic non-epileptic seizures with pain syndromes.
Devise strategies to address the identified challenges in order to provide empathic, appropriate, and cost-effective care for patients with PNES and pain syndromes.