tag:blogger.com,1999:blog-2186593343917545414.post907974464288848803..comments2024-03-10T12:29:30.004-07:00Comments on pediatric neurology: SyncopeGalen Breningstall, MDhttp://www.blogger.com/profile/07170864203251456228noreply@blogger.comBlogger4125tag:blogger.com,1999:blog-2186593343917545414.post-88402990744921406342015-12-23T13:43:20.016-08:002015-12-23T13:43:20.016-08:00(continued)If a standing provocation test were per...(continued)If a standing provocation test were performed on all patients with syncope unexplained by history, physical, and 12-lead ECG, a notable and larger proportion with PPS might be found and coincidence with VVS may be less. In parallel, most patients with PNEE do not have coexisting epilepsy.<br /><br />While psychogenic symptoms or signs exist in all specialties, PNEE are the most provable of all psychogenic symptoms, so they have been well-studied. Since the advent of EEG-video monitoring, a consistent finding at epilepsy centers is that about 30% of patients with refractory seizures actually have PNEE.<br /><br />All specialties have their equivalent psychogenic symptoms: shortness of breath and cough in pulmonary medicine, constipation and abdominal pain in gastroenterology, blindness in ophthalmology, dysphonia or globus in otolaryngology. Interestingly, pain is the least provable psychogenic symptom, so much so that the diagnosis of psychogenic pain is no longer accepted. Chronic pain conditions, such as fibromyalgia, continue to be controversial as to whether they are organic or psychogenic. Common features of psychogenic symptoms exist, whichever the specialty. They are first diagnosed as, and may coexist with, the mimicked organic illness. In general, most patients with psychogenic symptoms are not consciously faking (factitious, malingering) but rather fall under the unconscious category (formerly somatoform disorders, now somatic symptom disorders). It then follows that if 30% of refractory seizures are psychogenic, it is possible that 30% of refractory unexplained syncope is psychogenic, or partly embellished by a psychogenic component.<br /><br />The last and unfortunate feature of psychogenic symptoms across all specialties is that it is difficult to find good treatment. At least for PNEE, there is recent evidence that selective serotonin reuptake inhibitors and cognitive-behavioral therapy can be effective. This may not be the case for PPS, but successful treatment depends on rarely encountered mental health professionals, most of whom pay little attention and show little interest in this category of disorders.Galen Breningstall, MDhttps://www.blogger.com/profile/07170864203251456228noreply@blogger.comtag:blogger.com,1999:blog-2186593343917545414.post-47733597240683702402015-12-23T13:41:10.070-08:002015-12-23T13:41:10.070-08:00Benbadis SR, Sutton R. Psychogenic symptoms are no...Benbadis SR, Sutton R. Psychogenic symptoms are not only for the epileptologist: All physicians be aware! Neurology. 2015 Dec 8;85(23):2000-1.<br /><br />Among all psychogenic symptoms, psychogenic nonepileptic events (PNEE) are by far the best studied. We will use the term “events” in order to avoid the confusing term “seizures” here. Within neurology, movement disorders are also relatively well-documented and studied. In cardiology, common psychogenic symptoms are noncardiac chest pain and psychogenic pseudosyncope (PPS). The pathophysiology, or rather psychopathology, is similar for psychogenic symptoms regardless of the presenting symptoms. For patients with spells or fits, whether they are labeled PPS or PNEE depends mostly on what they resemble more (shaking = seizure, limp = syncope) and to which specialist they present...<br /><br />In this issue of Neurology, Blad et al. report a sizeable group of patients with both vasovagal syncope (VVS) and PPS. The 2 coexisted more than they should by chance. Not surprisingly, the red flags that suggested a psychogenic origin were similar to those that are well established for PNEE.<br /><br />This study is an important illustration of embellishment, or exaggeration of organic symptoms. Thus, the symptoms here can be viewed as partially psychogenic. The tilt-table procedure, like any medical procedure, acts like a provocative technique both in suggestible patients, those with PPS,and in those constitutionally vulnerable to vasodepression. Embellishment is similar to subconsciously learning from VVS symptoms and signs to manifest PPS...<br />The findings of Blad et al. have important practical implications. Internists and cardiologists who evaluate syncope should consider the diagnosis of PPS more often and earlier, just like most neurologists have learned to consider the diagnosis of PNEE in patients with refractory seizures. .. <br /><br />Another important lesson is that tilt-table tests would offer enhanced diagnostic capability by being performed routinely with EEG monitoring. Ictal recording easily distinguishes organic syncope (of any cause) and PPS, due to a predictable and sensitive series of changes. For routine EEG monitoring during tilt to be achieved, close cooperation between neurologist and cardiologist is necessary and is usually lacking. A potential limitation of the benefit of EEG monitoring is that EEG changes may not be present (false-negative) in incomplete or presyncope (e.g., dizziness, lightheadedness), but this is no different from ictal EEG being negative in mild or limited simple partial seizures...(continued)Galen Breningstall, MDhttps://www.blogger.com/profile/07170864203251456228noreply@blogger.comtag:blogger.com,1999:blog-2186593343917545414.post-52669839730092885562015-12-23T13:07:19.539-08:002015-12-23T13:07:19.539-08:00Raj V, Rowe AA, Fleisch SB, Paranjape SY, Arain AM...Raj V, Rowe AA, Fleisch SB, Paranjape SY, Arain AM, Nicolson SE. Psychogenic pseudosyncope: diagnosis and management. Auton Neurosci. 2014 Sep;184:66-72.<br /><br />Abstract<br /><br />Psychogenic pseudosyncope (PPS) is the appearance of transient loss of consciousness (TLOC) in the absence of true loss of consciousness. Psychiatrically, most cases are classified as conversion disorder, which is hypothesized to represent the physical manifestation of internal stressors. The incidence of PPS is likely under-recognized and the disorder is under investigated in the unexplained syncope population, yet it can be diagnosed accurately with a focused history and confirmed with investigations including head-up tilt testing (HUTT), electroencephalogram (EEG; sometimes combined with video) or, in some centers, transcranial Doppler (TCD). Patients are more likely to be young females with an increased number of episodes over the past 6months. They frequently experience symptoms prior to their episodes including light-headedness, shortness of breath and tingling. Conversion disorder is associated with symptomatic chronicity, increased psychiatric and physical impairment, and diminished quality of life. Understanding the epidemiology, biological underpinnings and approach to diagnosis of PPS is important to improve the recognition of this disorder so that patients may be managed appropriately. The general treatment approach involves limiting unnecessary interventions, providing the patient with needed structure, and encouraging functionality. While there are no treatment data available for patients with PPS, studies in related conversion disorder populations support the utility of psychotherapy. Psychotropic medications should be considered in patients with comorbid psychiatric disorders. Galen Breningstall, MDhttps://www.blogger.com/profile/07170864203251456228noreply@blogger.comtag:blogger.com,1999:blog-2186593343917545414.post-81993102751259143432015-12-22T16:12:22.238-08:002015-12-22T16:12:22.238-08:00Blad H, Lamberts RJ, Gert van Dijk J, Thijs RD. Ti...Blad H, Lamberts RJ, Gert van Dijk J, Thijs RD. Tilt-induced vasovagal syncope and psychogenic pseudosyncope: Overlapping clinical entities. Neurology. 2015 Dec 8;85(23):2006-10.<br /><br />Abstract<br /><br /><br />OBJECTIVE: <br /><br />To describe the combination of tilt-induced vasovagal syncope (VVS) and psychogenic pseudosyncope (PPS) and aid its clinical recognition.<br /><br />METHODS: <br /><br />We identified people with tilt-induced VVS/PPS from 2 tertiary syncope referral centers. For each case, 3 controls with tilt-induced VVS were selected at random from the same center. Clinical characteristics were compared between both groups adjusting for multiple comparisons.<br /><br />RESULTS: <br /><br />Of 1,164 tilt-table tests, 23 (2%) resulted in VVS/PPS; these 23 cases were compared with 69 VVS controls. VVS and PPS coincided more often than chance would predict: 2% vs 0.6%, p < 0.001. Typical VVS prodromes and triggers were reported in all people with VVS/PPS and in controls with VVS. Attack frequency was significantly higher in the VVS/PPS (2 per month, range 0.1-60) than in the VVS group (0.25 per month, range 0.02-4; p < 0.001). Delayed recovery of consciousness was more frequently reported in the VVS/PPS group (likelihood ratio [+LR] 8.14, 95% confidence interval [CI] 3.94-16.84), as well as episodes without prodromes (+LR 5.57, 95% CI 2.53-12.26), atypical triggers (+LR 5.00, 95% CI 2.04-12.24), eye closure (+LR 3.75, 95% CI 1.68-8.35), and apparent loss of consciousness >1 minute (+LR 2.86, 95% CI 1.98-4.13).<br /><br />CONCLUSIONS: <br /><br />VVS/PPS presents with a complex phenotype. High attack frequency, delayed recovery of consciousness, apparent loss of consciousness >1 minute, ictal eye closure, atypical triggers, and the absence of prodromes may serve as indicators that PPS coincides with VVS.Galen Breningstall, MDhttps://www.blogger.com/profile/07170864203251456228noreply@blogger.com