Shame, Pediatric PNES, and COVID-19

The recent papers on shame in patients with psychogenic nonepileptic seizures (PNES) are noteworthy [[1]Reuber M. Roberts N.A. Levita L. Gray C. Myers L. Shame in patients with psychogenic nonepileptic seizure: a narrative review.Seizure. 2021; (in press)https://doi.org/10.1016/j.seizure.2021.10.017Abstract Full Text Full Text PDF Scopus (5) Google Scholar,[2]Myers L. Gray C. Roberts N. Levita L. Reuber M. Shame in the treatment of patients with psychogenic nonepileptic seizures: the elephant in the room.Seizure. 2021; (in press)https://doi.org/10.1016/j.seizure.2021.10.018Abstract Full Text Full Text PDF Scopus (5) Google Scholar]. The emotion of shame has not received its due recognition in the pathophysiology of PNES. We agree with the authors on the difficulties of assessing this emotion owing to its subjectivity and possible inability of patients to identify, understand, and phrase it [[1]Reuber M. Roberts N.A. Levita L. Gray C. Myers L. Shame in patients with psychogenic nonepileptic seizure: a narrative review.Seizure. 2021; (in press)https://doi.org/10.1016/j.seizure.2021.10.017Abstract Full Text Full Text PDF Scopus (5) Google Scholar]. Another important reason for fewer discussions on the subject may be the unawareness of the treating professionals. We appreciate the authors for trying to set the ball rolling. We would like to share our thoughts on shame in pediatric PNES and the imminent impact of the changing social fabric and COVID-19 pandemic in this context. There is a paucity of literature on shame in pediatric PNES. However, the studies describing the stressors (such as bullying, body image issues, low self-esteem) and psychiatric co-morbidities in pediatric PNES provide indirect evidence for the role of this emotion [[3]Madaan P. Gulati S. Chakrabarty B. Sapra S. Sagar R. Mohammad A. et al.Clinical spectrum of psychogenic non epileptic seizures in children; an observational study.Seizure. 2018; 59: 60-66https://doi.org/10.1016/j.seizure.2018.04.024Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar]. Also, the phenomenology of dialeptic PNES (the commonest semiology in pediatric PNES) resembles the body language associated with shame (shoulder slump, downward head movement, and collapse of upper torso) [[3]Madaan P. Gulati S. Chakrabarty B. Sapra S. Sagar R. Mohammad A. et al.Clinical spectrum of psychogenic non epileptic seizures in children; an observational study.Seizure. 2018; 59: 60-66https://doi.org/10.1016/j.seizure.2018.04.024Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar,[4]Szabo L. Siegler Z. Zubek L. et al.A detailed semiologic analysis of childhood psychogenic nonepileptic seizures.Epilepsia. 2012; 53: 565-570Crossref PubMed Scopus (82) Google Scholar]. Hence, future studies exploring this emotion in pediatric PNES are needed. The authors have methodically discussed the developmental trajectory of shame and the role of poor parenting and traumatic experiences in atypical shame development [[1]Reuber M. Roberts N.A. Levita L. Gray C. Myers L. Shame in patients with psychogenic nonepileptic seizure: a narrative review.Seizure. 2021; (in press)https://doi.org/10.1016/j.seizure.2021.10.017Abstract Full Text Full Text PDF Scopus (5) Google Scholar]. We would like to add on the potential influence of changing social fabric and COVID-19 pandemic in this context. With social media being ubiquitous, the fear of being continuously judged and scrutinized from an early age can affect the developmental trajectory of self-conscious emotions including shame. The COVID-19 pandemic has further heightened social media exposure beginning from early childhood. Besides, the traumatic experiences and scars of this pandemic have impacted the mental health of children and are likely to atypically shape these emotions and influence their long-term mental health [5Panda P.K. Gupta J. Chowdhury S.R. Kumar R. Meena A.K. Madaan P. et al.Psychological and behavioral impact of lockdown and quarantine measures for COVID-19 pandemic on children, adolescents and caregivers: a systematic review and meta-analysis.J Trop Pediatr. 2021; 67: fmaa122Crossref PubMed Scopus (280) Google Scholar, 6Sharma M. Aggarwal S. Madaan P. Saini L. Bhutani M. Impact of COVID-19 pandemic on sleep in children and adolescents: a systematic review and meta-analysis.Sleep Med. 2021; 84: 259-267https://doi.org/10.1016/j.sleep.2021.06.002Crossref PubMed Scopus (51) Google Scholar, 7Aggarwal S. Madaan P. Pediatric mental health during COVID-19 pandemic: concerns in developing countries.J Trop Pediatr. 2021; (in press)https://doi.org/10.1093/tropej/fmab099Crossref PubMed Scopus (1) Google Scholar]. Few small studies on adults with PNES during the pandemic showed a higher frequency of events [[8]Valente K.D. Alessi R. Baroni G. Marin R. Dos Santos B. Palmini A. The COVID-19 outbreak and PNES: the impact of a ubiquitously felt stressor.Epilepsy Behav. 2021; 117107852https://doi.org/10.1016/j.yebeh.2021.107852Abstract Full Text Full Text PDF Scopus (19) Google Scholar,[9]Asadi-Pooya A.A. Farazdaghi M. Effects of the COVID-19 pandemic on characteristics of functional (psychogenic) seizures.J Psychosom Res. 2021; 147110514https://doi.org/10.1016/j.jpsychores.2021.110514Crossref Scopus (5) Google Scholar]. However, the increase or decrease in the population burden of PNES during the pandemic is unclear. With limited literature and difficulties in research on the burden of PNES, it will be difficult to assess the long-term impact of the pandemic on PNES burden [[10]Asadi-Pooya A.A. Sperling M.R. Epidemiology of psychogenic nonepileptic seizures.Epilepsy Behav. 2015; 46 (May): 60-65https://doi.org/10.1016/j.yebeh.2015.03.015Abstract Full Text Full Text PDF PubMed Scopus (191) Google Scholar]. The authors have no conflict of interest to disclose with regard to this. None.