A 6-year symptom survival analysis of 17 patients admitted as in-patients and/or day patients to the tertiary psychiatric ward at Birmingham Children’s Hospital, UK, for pseudoseizures, without concomitant epilepsy, was conducted using case-note data. Fourteen patients had recovered and returned to school. Three were lost to follow-up. A “cure” was defined as freedom from seizures for six months. Females outnumbered males by 15 to 2. Mean age of admission was 12 years, 9 months (range, 8 to 15 years). Seizure types were varied, usually “swoon” or “thrashing’ in pattern. Seizure frequency ranged from 1 to 70 a week, mean of 18/wk. Duration of symptoms until diagnosis was 12 months, range 1 to 59 months. Eight patients were taking anticonvulsants at diagnosis. Additional symptoms included headache (8 patients), abdominal pain (4), dizziness (3), and anxiety/panic (3). All had normal intelligence, but academic difficulties occurred in 7 children. Bullying was the cause in 4 of 10 with poor school attendance. A past history of traumatizing sexual experience was obtained in 4. Twelve were treated as in-patients, 11 as day patients, and 6 in both. Good outcome was associated with younger age at onset, a lower seizure frequency at presentation, and treatment in only one setting. Patients requiring both in-patient and day care had a slightly worse outcome.
Treatment included distraction by rehabilitation and milieu therapy, attendance at the hospital school, and anticonvulsant withdrawal in a mean 12 week period. The aim of milieu therapy is to allow the child to escape with honor from sick role behavior (Dubowitz and Hersov 1976). Children are encouraged to engage in normal activities to distract them from preoccupation with seizures. Apart from safety precautions, seizure occurrence is largely ignored by staff, focussing on coping mechanisms, relaxation, anxiety and stress management, and widening family support. Reintegration to regular school is gradual. Recovery followed an exponential distribution, with a mean symptom survival time following treatment of 1.5 years, consistent with a treatment effect. 
COMMENT. The successful management of pseudoseizures at the Birmingham Children’s Hospital, UK, is impressive and appears to be related to the non-critical, “milieu” method of rehabilitation employed, and the compassionate understanding and attention of supportive hospital staff and school teachers.
The less pejorative term “nonepileptic” seizures of psychogenic origin is sometimes preferred to pseudoseizures or psychogenic seizures. True seizures may occur in the same patient, and frontal lobe seizures are often misdiagnosed as nonepileptic. Frontal lobe or extratemporal seizures frequently present as unusual and violent generalized thrashing movements, with nonspecific EEG findings, and conventional anticonvulsants may be only partially effective. Attacks are usually nocturnal but can be diurnal in more than 50% of patients. (See Progress in Pediatric Neurology III, 1997;pp87-88).