Diagnosis of Pediatric PNES

Abstract

The Underlying Psychopathology, Triggers, and Risk Factors As briefly mentioned in the overview to this treatment guide, the underlying psychopathology of children with PNES, conversion disorder, involves displacement of the tension associated with negative emotions, such as anxiety, anger, fear, frustration, and demoralization onto physical symptoms. Why certain children develop conversion disorder with epilepsy-like symptoms rather than other physical symptoms remains unclear [1, 2]. However, current psychodynamic theories on pediatric PNES and evidence for triggers (see review in [3]) and risk factors [4]) shed light on ways the disorder might develop. From the research perspective, triggers for pediatric PNES include learning difficulties ; social problems; parent marital discord; family dysfunction; unrealistic expectations by the child or the parents for the child to excel at school, sports, or extracurricular activities; bullying and other forms of psychological abuse; and rarely physical or sexual abuse [5-9]. But not every child who experiences these trigger factors develops PNES. Two independent risk factors differentiate children with PNES from their siblings, a somatopsychiatric factor and an adversity factor [10]. In other words, children with medical problems, excessive use of medical services, fearful response to physical sensations, and psychiatric diagnoses-the somatopsychiatric factors-are at risk for PNES. Bullying associated with emotional problems, psychiatric diagnoses, and treatment with psychiatric drugs-the adversity factors-also increase the vulnerability for PNES. From the psychodynamic perspective, children who develop PNES and other conversion disorders [11] appear to use avoidance when faced with situations that trigger negative emotions (fear, anger, frustration, anxiety, or sadness). In addition to not confronting and/or problem-solving the situation that triggers these negative feelings, these children are often unaware of or deny experiencing negative emotions. Thus, they are avoidant on both the functional and emotional levels. In some cases, the children have language difficulties with impaired use and/or retrieval of words to describe their emotions (alexithymia) (see review in Reilly et al. [3]) and/or