Overview
Definition:
Functional seizures (FS), also known as psychogenic non-epileptic seizures (PNES), are episodes that resemble epileptic seizures but are not caused by abnormal electrical discharges in the brain
They are considered a manifestation of a functional neurological disorder where there is a problem with how the nervous system functions, rather than structural damage
In children, these seizures are often triggered or exacerbated by psychological stress, trauma, or underlying emotional distress.
Epidemiology:
Functional seizures account for approximately 10-20% of cases referred to epilepsy centers
They are more common in adolescents and young adults, with a higher incidence in females
In pediatric populations, estimates suggest 2-10 per 100,000 children experience FS annually
Early and accurate diagnosis is crucial to avoid misdiagnosis as epilepsy and inappropriate treatment.
Clinical Significance:
Effective communication is paramount in managing children with functional seizures
It influences accurate diagnosis, fosters trust, facilitates appropriate management, and improves patient and family coping
Miscommunication can lead to delayed diagnosis, unnecessary antiepileptic drug (AED) use, social isolation, and significant psychological distress for the child and family
Understanding the nuances of communicating with pediatric patients and their caregivers is vital for improving outcomes and preparing for DNB and NEET SS examinations.
Communication Principles
Empathetic Approach:
Acknowledge the reality of the patient's experiences and distress
Avoid judgmental language
Validate their feelings and concerns
Focus on the symptoms and the impact on their life.
Clear Language:
Use simple, age-appropriate language
Avoid medical jargon
Explain complex concepts in a straightforward manner
Ensure understanding by asking open-ended questions and encouraging them to rephrase.
Active Listening:
Pay close attention to verbal and non-verbal cues
Allow the patient and family to express themselves fully without interruption
Summarize what you have heard to confirm understanding
Demonstrate genuine interest and concern.
Inclusivity Of Family:
Recognize that the family is integral to the child's care
Involve parents or guardians in discussions
Provide them with information and support
Address their concerns and anxieties about the child's condition and prognosis.
Diagnostic Communication
History Taking:
When taking history, focus on detailed descriptions of the spells, including onset, duration, precipitating factors, and associated behaviors
Ask about emotional states before, during, and after episodes
Inquire about stressors, family dynamics, and any history of trauma or significant life events
Be sensitive and reassuring throughout the interview.
Explaining Diagnosis:
When delivering the diagnosis of functional seizures, present it in a supportive and non-stigmatizing way
Explain that the symptoms are real and distressing, but not due to a "fault" in the brain's electrical activity like epilepsy
Emphasize that it is a treatable condition and focus on a multidisciplinary approach
Use analogies to help explain the concept of a functional disorder
Reassure them that the goal is to help them regain control over their bodies.
Addressing Skepticism:
Parents and patients may be skeptical or have had previous diagnoses of epilepsy
Acknowledge their prior experiences and diagnostic journey
Present evidence from investigations (e.g., prolonged EEG without correlating events) gently
Focus on shared goals of symptom relief and improved quality of life
Frame the diagnosis as a pathway to more effective management, not a dismissal of their experiences.
Management Communication
Treatment Plan Discussion:
Clearly outline the treatment plan, which typically involves a multidisciplinary approach including psychotherapy (e.g., cognitive behavioral therapy, counseling), physiotherapy, and potentially medication for co-occurring conditions like anxiety or depression
Explain the rationale behind each component of the treatment
Set realistic expectations for recovery.
Role Of Psychotherapy:
Explain that psychotherapy aims to help the child and family understand and manage the triggers for the seizures, develop coping mechanisms, and address underlying emotional or psychological factors
Highlight that this is a key component for recovery and should not be viewed as secondary to medical treatment.
Managing Expectations AEDs:
If the child has been previously treated with AEDs, discuss the rationale for tapering them off if they are ineffective for FS
Explain that AEDs do not typically help functional seizures and can have side effects
Emphasize that the focus will shift to non-pharmacological interventions
If psychiatric medications are prescribed, clearly explain their purpose and expected benefits.
Relapse Prevention Communication:
Educate the patient and family about signs of potential relapse and strategies for managing triggers and stress
Encourage them to maintain open communication with the healthcare team
Empower them to recognize early warning signs and seek support proactively.
Communication Challenges And Solutions
Stigma And Shame:
Functional seizures can carry significant stigma
Use person-first language ("a child with functional seizures") and avoid stigmatizing terms
Foster an environment of trust and understanding where the patient feels safe to discuss their experiences without fear of judgment.
Anxiety And Fear:
Patients and families are often anxious about the unknown and the impact on daily life
Provide consistent reassurance and support
Clearly explain what to expect at each stage of diagnosis and treatment
Address their fears directly and empathetically.
Doctor Patient Relationship:
Building a strong therapeutic alliance is crucial
Maintain consistency in care providers where possible
Be present, attentive, and approachable
Regular follow-ups with open communication channels are essential for long-term management and success.
Key Points
Exam Focus:
DNB/NEET SS questions often revolve around differentiating functional seizures from epilepsy, the importance of a thorough psychosocial history, and the multidisciplinary management approach
Communication skills are indirectly tested through case scenarios.
Clinical Pearls:
Always begin by validating the patient's experience
Use "functional" as a descriptor rather than "psychogenic" initially to reduce stigma
Focus on empowerment and recovery, not on the "cause" of the seizures
Involve a mental health professional early in the management plan.
Common Mistakes:
Dismissing the patient's experiences as "not real"
Delaying the diagnosis by focusing solely on ruling out epilepsy without adequate psychosocial assessment
Prescribing AEDs long-term for unconfirmed epilepsy when FS is suspected
Failing to involve the family in the treatment plan.