Cognitive functioning in children and adolescents with multiple sclerosis.

OBJECTIVE: To examine cognitive functioning in children with multiple sclerosis (MS). METHODS: The authors examined the neuropsychological profile of 37 children with a diagnosis of clinically definite MS and assessed the associations between cognitive function and clinical features. RESULTS: Of 37 children and adolescents evaluated, 35% demonstrated significant cognitive impairment. Cognitive functioning was strongly related to several clinical variables, including current Expanded Disability Status Scale, total number of relapses, and total disease length. The consequences of MS adversely affected academic functioning in over a third of the children. CONCLUSIONS: Cognitive deficits occur in children with multiple sclerosis. Comprehensive treatment planning should involve recognition that they may require academic accommodations for their education.

Headaches and other pain symptoms among patients with psychogenic non-epileptic seizures.

Studies of patients with psychogenic non-epileptic seizures (NES) typically focus upon the phenomenology and outcome of NES episodes. Little is known, however, about the frequency and nature of other somatic symptoms such as pain, in this population. To assess the frequency, location and severity of symptoms of pain among NES patients, we administered structured interviews to 56 patients, 6 or more months following the diagnosis of psychogenic non-epileptic seizures (NES). Patients were recruited from a tertiary hospital-based epilepsy monitoring unit. Seventy-seven percent of patients suffered from moderate to severe pain, most commonly headache (61%), while neck pain and backache were also common. Twenty-six of 27 patients with persistent NES vs. 17 of 29 patients whose NES resolved experienced moderate to severe pain (P < 0.001). Pain is an under-recognized problem that occurs frequently and with significant severity among NES patients. Pain symptoms are more common among patients with persistent NES than those whose NES resolve.

Predictive factors for outcome of nonepileptic seizures after diagnosis.

The aim of this study was to assess prognosis among adult patients with nonepileptic seizures (NES) and to determine predictor variables for resolution of NES after diagnosis. Six to 9 months after receiving a video-EEG-documented diagnosis of NES, 43 adults responded by telephone interview to a detailed, structured questionnaire probing history of the episodes, psychiatric factors, socioeconomic variables, relationships, reactions to receiving the diagnosis, and potential history of litigation. At follow-up, only 18.6% were episode-free, 55.8% had improved, 16.3% reported no change, and 9.3% reported greater frequency of episodes. Patients who reported having many friends currently or having good relationships with friends as a child were significantly more likely to be episode-free. Subjects with pending litigation were significantly less likely to experience a reduction in episodes.

A comprehensive profile of clinical, psychiatric, and psychosocial characteristics of patients with psychogenic nonepileptic seizures.

PURPOSE: To attain a comprehensive profile of clinical, psychiatric and psychosocial characteristics of patients with psychogenic nonepileptic seizures (NESs), and to assess the relation of these factors to NES outcome. METHODS: We administered a telephone-based structured questionnaire to 56 patients with NESs (16 male and 40 female patients; mean age, 35 years) at a mean follow-up time of 18 months after making the diagnosis of NES. RESULTS: Mean age of NES onset was 28 years with a mean duration of 8 years. Episodes resolved in 29 (51.8%) cases, decreased in 24 (42.9%), persisted unchanged in two (3.6%), and increased in frequency in one (1.8%). Thirty (53.6%) patients, including 13 (44.8%) of patients whose NESs resolved, were rehospitalized for NESs or for other symptoms. Twenty-nine (51.8%) had significant depressive symptoms, 22 (39.3%) had suicidal ideation, and 11 (19.6%) attempted suicide [including 6 (21%) of the patients whose NESs resolved]. Believing the NES diagnosis was associated with resolution or improvement of NES frequency (p<0.029), whereas anger in response to receiving the diagnosis did not predict a poorer outcome. Patients' perceptions of having good health (p<0.02) and good occupational functioning (p<0.04) were highly correlated with NES resolution. Only patients whose episodes resolved were employed at the time of follow-up. CONCLUSIONS: At a mean of 1.5 years, NES outcome was poor, with resolution in only half the group and with frequent rehospitalizations after NES diagnosis, even among patients whose NES resolved. Depressive symptoms, suicidal ideation, and suicide attempts were common. Believing the NES diagnosis and patient perceptions of having good health and good occupational functioning correlated well with NES resolution.

Postictal symptoms help distinguish patients with epileptic seizures from those with non-epileptic seizures.

The aim of the study was to assess whether post-ictal symptoms can help distinguish patients who have epileptic seizures from those with non-epileptic seizures (NES). We reviewed the spontaneous responses to the question 'What symptoms do you have after a seizure?' in 16 patients with epileptic seizures (predominantly focal with secondary generalization or generalized tonic-clonic) and 23 NES patients. Six of the 16 patients (38%) vs. only one of 23 NES patients (4.3%) noted post-ictal headache (P = 0.008). Nine epilepsy patients (56%) vs. three NES patients (13%) reported post-ictal fatigue (P = 0.004). Confusion or other symptoms did not distinguish epilepsy patients from those with NES. All epilepsy patients had at least one post-ictal symptom while 12 NES patients (52%) had none (P = 0.001). Therefore, patients evaluated for epileptic vs. non-epileptic seizures who have post-ictal fatigue or headache, are more likely to have epileptic seizures. Patients with a diagnosis of NES who note post-ictal fatigue or headache should be investigated further.

Positive and negative psychotropic effects of lamotrigine in patients with epilepsy and mental retardation.

PURPOSE: To describe significant positive or negative psychotropic effects of lamotrigine (LTG) observed in epilepsy patients with mental retardation (MR). METHODS: Seven mentally retarded epilepsy patients, [5 with Lennox-Gastaut syndrome (LGS)] who experienced significant behavioral improvements or worsening after addition of LTG to their medication regimen were studied. RESULTS: LTG produced behavioral improvements in 4 patients. Patient 1, a 14-year-old girl, had LTG added to valproate (VPA) and thioridazine, resulting in diminished lethargy, less hyperactivity, and more appropriate speech. In a 17-year-old boy (patient 2) LTG added to VPA, phenytoin (PHT), and gabapentin (GBP) lessened irritability and hyperactivity. In patient 3, a 41-year-old woman, LTG added to PHT, VPA, and carbamazepine (CBZ) diminished lethargy and enhanced her social interactions. In patient 4, a 27-year-old man, LTG monotherapy diminished irritability and hyperactivity. Adverse behavioral effects were noted in 3 patients. In patient 5, a 43-year-old man, LTG added to PHT, phenobarbital (PB), lorazepam, sertraline, and thioridazine produced irritability, hyperactivity, and poor cooperation. In patient 6, a 29-year-old woman, LTG added to VPA produced frequent screaming, temper tantrums, increased rocking movements, and hyperactivity. In patient 7, a 29-year-old man, LTG added to VPA and PHT resulted in severe exacerbation of baseline behaviors, including self-injurious activity, temper tantrums, and failure to obey simple instructions. CONCLUSIONS: In some patients with epilepsy and MR, LTG has significant positive or negative effects on behavior.

Symptoms of depression and anxiety in pediatric epilepsy patients.

PURPOSE: We assessed rates of symptoms of anxiety and depression among pediatric patients with epilepsy. METHODS: We administered the Revised Child Manifest Anxiety Scale (RCMAS), and Child Depression Inventory (CDI) to 44 epilepsy patients aged 7-18 years (mean age 12.4 years). Demographic, socioeconomic, and epilepsy-related information was examined in relation to depression and anxiety scores. RESULTS: No patients had been previously identified to have depression or anxiety. However, 26% had significantly increased depression scores and 16% met criteria for significant anxiety symptomatology. CONCLUSIONS: Symptoms of depression and anxiety are common among pediatric patients with epilepsy and appear to be overlooked by care providers.

Felbamate-induced headache.

We prospectively investigated drug-induced headaches (HA) among 60 epileptic patients receiving felbamate (FBM). Twenty patients (33%) experienced HA. HA was pounding in 11 (55%), steady in 9 (45%), moderate or severe in 19 (95%), occurred at least once a week in all patients, and was relieved by nonnarcotic analgesics in 14 (70%). Mean duration on FBM before HA onset was 19 days. HA occurred with higher FBM doses and was relieved in 8 of 13 patients (62%) with FBM dose reduction. FBM was discontinued in most cases because of risks of anemia or hepatitis; not because of HA. Other side effects included insomnia (25%), gastrointestinal symptoms (27%), and agitation or restlessness (23%). HA is a common dose-related complication of FBM, occurs early after initiation of FBM treatment, and is relieved by dose reduction.

The politics of sexuality in adolescent psychiatry.

The purpose of this paper is to examine and analyze policies towards adolescent sexuality within a total institution. The issues are discussed from the perspective of 4 different domains: clinical, experiential, ethical, and theoretical. Considerations from all 4 domains interact. When the interactions are not made explicit, it is possible that 1 domain may override the others. This, in turn, may produce undesirable side effects such as defensive justifications of policies or distortions of the less favored domains. Included among the issues examined are: policies regarding sexual relationships between patients who are simultaneously engaged in psychotherapeutic relationships; institutional rulings on sexual behaviors; coeducational units for adolescents; and decision making about birth control and abortion for adolescent psychiatric patients. Clinical illustrations from a residential treatment unit for severely disturbed adolescents are provided. Within the context of adolescent sexuality, the 2 diametrically opposed models of psychiatric institutions are contrasted. The 1st is based on ethical concepts of autonomy and antitotalitarianism, while the 2nd model uses a clinical paradigm which recognizes psychodynamic intricacies as well as the restricted autonomy of severely disturbed adolescent patients. When this latter approach is taken to the extreme, it prescribes profound limitations on patients' behaviors, particularly those behaviors with sexual etiologies. In actuality, these 2 models form the poles of a myth. The clinical pole functions entirely within a model that does not allow for individual and ethical considerations while the ethical pole denies psychodynamic complexities. It is obvious that quite different administration decisions will stem from the respective models. A comprehensive framework for discussion of the politics of sexuality in adolescent psychiatry utilizing all 4 domains is proposed. To that effect, the current ethical and clinical myths should be critically analyzed, discussed, and then transcended.