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Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: A case report
General Hospital Psychiatry xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: A case report Xavier F. Jimenez, M.D. ⁎, Jennifer S. Sharma, M.D., Syma A. Dar, M.D. Cleveland Clinic Foundation, Department of Psychiatry and Psychology, 9500 Euclid Avenue, P57, Cleveland, OH 44195, USA
a r t i c l e
i n f o
Article history: Received 22 May 2014 Revised 27 June 2014 Accepted 30 June 2014 Available online xxxx Keywords: Conversion disorder Psychogenic nonepileptic seizures Cancer Medical stressor
a b s t r a c t Psychogenic nonepileptic seizures (PNES), a form of conversion disorder, are paroxysmal episodes resembling epilepsy while lacking electrographic correlation. The phenomenon has rarely been reported in elderly patients and has not been associated with a new-onset medical diagnosis. We present the case of an 81-year-old female with no past psychiatric or traumatic history who developed PNES within the context of a new, suspected cancer. To our knowledge, this is the first such reported case of a suspected cancer (or otherwise medical) diagnosis contributing directly and temporally to the development of PNES. Discussion of involved psychosocial variables follows the vignette, and a brief review of relevant literature is offered. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Psychogenic nonepileptic seizures (PNES), a form of conversion disorder, are paroxysmal episodes resembling epileptiform seizures while lacking video electroencephalogram (VEEG) correlation [1]. PNES are often diagnosed in young and psychiatrically burdened females; remote and/or ongoing trauma is often implicated, yet acute stressors may be difficult to identify [2]. Various psychiatric reactions to medical illness are possible, including posttraumatic stress disorder [3] and depression with suicidal ideation [4]. There is no literature demonstrating development of PNES upon receiving a new medical diagnosis. We present a case of PNES emerging in the context of a suspected cancer diagnosis in an elderly patient. 2. Clinical vignette Ms. M is an 81-year-old African-American female with a history of stage III kidney disease and chronic, asymptomatic hematologic abnormalities (anemia and thrombocytopenia). She presented to a community hospital with dehydration and diarrhea lasting 5 days, diagnosed with gastroenteritis secondary to food poisoning. Laboratory analysis revealed baseline anemia and thrombocytopenia but no other abnormalities, although some clinical speculation regarding an underlying myelodysplastic process was communicated by the medical teams. On arrival, Ms. M developed frequent, timelimited (under a minute), high-amplitude head-shaking “spells.” Maintaining alertness throughout, she responded to commands ⁎ Corresponding author. E-mail address: [email protected] (X.F. Jimenez).
without subsequent confusion or sensorimotor sequelae. Though less than elaborative, Ms. M was able to describe these as moments of high anxiety but with preserved attention and recollection; she denied linking these to any particular thoughts, feelings or events. Brain magnetic resonance imaging revealed mild, generalized volume loss consistent with age and chronic ischemic microvascular disease but no acute pathology. Bedside electroencephalogram revealed no epileptiform activity or slowing. Psychiatry was consulted; a nonspecific anxiety disorder was offered as a diagnostic possibility, though no specific treatment followed. Upon resolution of gastrointestinal complaints, Ms. M transferred to a nursing facility for physical rehabilitation. While in there, PNES persisted, prompting referral to an epilepsy-monitoring unit (EMU). Psychiatry was re-consulted as numerous typical, consistent episodes occurred, each lacking VEEG correlation. Upon interview, Ms. M was cognitively intact (28/30 on the Mini Mental Status Examination). Although cooperative, she vehemently denied past or current psychiatric illness. Psychosocial history included a “happy childhood” and stable upbringing, lacking any trauma or abuse history. She was married for 40 years until her husband’s death 4 years prior. Since then she lived with her brother and maintained for herself. She cited many other supports, including extended family, friends and her church, and denied legal, military or substance abuse histories. Ms. M also denied financial, relational or legal stressors. When asked if aging had been difficult, she recognized she was “no longer a spring chick” but denied any fear of death. Fleetingly, she did state “the only thing that would stress me out is if I had cancer,” adding that a friend died of cancer in the past. Ms. M’s daughter, very active in her care, corroborated her accounts and baseline presentation; outpatient medical providers were similarly surprised by the PNES.
http://dx.doi.org/10.1016/j.genhosppsych.2014.06.012 0163-8343/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Jimenez X.F., et al, Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: A case report, Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.06.012
2
X.F. Jimenez et al. / General Hospital Psychiatry xxx (2014) xxx–xxx
Hematology was consulted to evaluate complete blood counts; they expressed high likelihood of a leukemic process, and a bone marrow biopsy revealed a myeloid neoplasm with increased blasts in bone marrow and peripheral blood suggesting a myeloproliferative neoplasm versus a high-grade myelodysplasia. Prior to this, Ms. M lacked any actual evidence of cancer; of note, at this point, additional history revealed she had missed a recent ambulatory bone marrow biopsy appointment before any of these hospitalizations. After diagnosis, Ms. M manifested no outward distress. She remained optimistic regarding prognosis but continually refused psychiatric follow-up on the grounds that she did not need “mental help” and that her symptoms were “real seizures” despite numerous attempts by both neurologists and psychiatrists at trying to explain conversion disorder as a stress-mediated or psychologically mediated condition. Oncology confirmed a lack of central nervous system cancerous manifestations. She transferred to a rehabilitation facility with subsequent oncological follow-up and persistent PNES episodes.
continually theorized to consist of neurobiological mechanisms, conceptualized by some authors as a parietal “unawareness” syndrome [15]. Despite these perspectives, cases marked by high suspicion of conversion disorder should be declared as such. Nondisclosure of a conversion disorder diagnosis in the hopes of preserving therapeutic alliance has resulted in unintended albeit serious harm [16]. Therapeutic mislabeling [17] sparing psychiatric diagnosis is often seen in neurological evaluations yet should be avoided. As mentioned, elderly patients in particular are at risk for delayed diagnosis of PNES, including iatrogenic harm from unwarranted antiepileptic medication exposure [8]. Future efforts might be directed at increased sensitivity to idiosyncratic or hysterical reactions to medical diagnoses. Considerations include wider use of psychological assessments such as the Minnesota Multiphasic Inventory or the Personality Assessment Inventory in medical populations in order to identify denial, somatization or hysterical patterns [18] perhaps aiding in the diagnosis of conversion disorder or PNES.
3. Discussion In this case, the stressor of a potential cancer diagnosis matched temporally with development of unexplained pseudoneurological symptoms. Interruptible, dramatic, high-amplitude head shaking lasting mere seconds and lacking VEEG correlation strongly suggests psychogenicity. There are no reports of a new suspected medical diagnosis — cancer or otherwise — contributing to or causing PNES. We conducted a search with the following keywords in various combinations: “nonepileptic seizure,” “pseudoseizure,” “conversion disorder,” “conversion reaction,” “medical diagnosis,” “cancer diagnosis,” “cancer” and “medical stressor.” Remarkably, only one [5] published case illustrates conversion symptoms mimicking chemotherapy adverse effects. Others described a functional neurological syndrome in acute lymphocytic leukemia, though symptoms were secondary to the stressor of actual treatment and were confounded by neurotoxic effects of vincristine [6]. Comparably rare are individual reports of conversion disorder beginning anew in the elderly [7,8], though retrospective analyses have shown that 10–17% of patients over 60 years of age admitted to an EMU were diagnosed with PNES [9,10]. Although demographic comparisons between younger and elderly PNES patients have revealed many similarities in regard to trauma history, symptomatology and psychological testing, the elderly have frequently encountered delays in the diagnosis of PNES [11], as analyses have suggested that the elderly more often are diagnosed with physiological (rather than psychogenic) nonepileptic seizures [12,13]. To our knowledge, this is the first report of a suspected medical diagnosis as the stressor resulting in or contributing to electrographically confirmed conversion disorder. We recognize the possibility of underappreciated or minimized histories of trauma or psychiatric illness. Conceptually, it may be that Ms. M’s intolerable cancer fear resulted in defenses of avoidance (missing outpatient oncological evaluation) and denial (superficial interview and history). In a paradoxical manner, PNES may have provided adaptive signaling of distress, forcing comprehensive medical evaluations resulting in an oncological diagnosis. 4. Conclusion Conversion disorder poses diagnostic difficulties, as one cannot confirm the condition with utmost certitude [14]. Furthermore, it is
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References [1] LaFrance WC, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia 2013;54(Suppl.1):53–67. [2] Fiszman A, Alves-Leon SV, Nunes RG, D’Andrea I, Figueira I. Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy Behav 2004;5(6):818–25. [3] Bienvenu OJ, Neufeld KJ. Post-traumatic stress disorder in medical settings: focus on the critically ill. Curr Psychiatry Rep 2011;13:3–9. [4] Kishi Y, Robinson RG, Kosier JT. Suicidal ideation among patients with acute lifethreatening physical illness: patients with stroke, traumatic brain injury, myocardial infarction, and spinal cord injury. Psychosomatics 2001;42:382–90. [5] Onishi H, Kamijo A, Onose M, Yamada T, Mizuno Y, Ito M, et al. Conversion disorder with convulsion and motor deficit mimicking the adverse effects of high-dose Ara-C treatment in a posttransplant acute myeloid leukemia patient: a case report and review of the literature. Palliat Support Care 2004;2:79–82. [6] Szajnberg NM, Zalneraitis E, Atlman AJ, Weisman SJ, Andrulonis PA. Atypical anorexia nervosa and hysterical symptomatology in a child with acute lymphocytic leukemia: a case management conference. Clin Pediatr 1989;28 (12):561–6. [7] Fakhoury T, Abou-Khalil B, Newman K. Psychogenic seizures in old age: a case report. Epilepsia 1993;34(6):1049–51. [8] Weddington WW. Conversion reaction in an 82-year-old man. J Nerv Ment Dis 1979;167(6):368–9. [9] Abubakr A, Wambacq I. Seizures in the elderly: video/EEG monitoring analysis. Epilepsy Behav 2005;7:447–50. [10] Behrouz R, Heriaud L, Benbadis SR. Late onset psychogenic nonepileptic seizures. Epilepsy Behav 2006;8:649–50. [11] Acar G, Salinksy MC. Demographic and historical backgrounds of the elderly with nonepileptic seizures: a comparative study. Neurol India 2010;58(1):48–52. [12] McBride AE, Schih TT, Hirsch LJ. Video-EEG monitoring in elderly: a review of 94 patients. Epilepsia 2002;43:165–9. [13] Kellinghaus C, Loddenkemper T, Dinner DS, Lachwani D, Luders HO. Non-epileptic seizures of the elderly. J Neurol 2004;251:704–9. [14] Nicholl JS. Pseudoseizures: a neuropsychiatric diagnostic dilemma. Psychosomatics 1981;22(5):451–4. [15] Perez DL, Barsky AJ, Daffner K, Silbersweig DA. Motor and somatosensory conversion disorder: a functional unawareness syndrome? J Neuropsychiatry Clin Neurosci 2012;24(2):141–51. [16] Kirschner KI, Smith GR, Antiel RM, Lorish P, Frost F, Kanaan RAA. “Doc, why can’t i move?” Ethical dilemmas in treating conversion disorders. PM R 2012;4:296–303. [17] Boissy A, Ford P. A touch of MS: therapeutic mislabeling. Neurology 2012;78 (24):1981–5. [18] Gale SD, Hill SW. Concurrent administration of the MMPI-2 and PAI in a sample of patients with epileptic or non-epileptic seizures: implications for an inpatient epilepsy monitoring unit. Epilepsy Behav 2012;25(2):181–4.
Please cite this article as: Jimenez X.F., et al, Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: A case report, Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.06.012
Contents lists available at ScienceDirect
General Hospital Psychiatry journal homepage: http://www.ghpjournal.com
Case Report
Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: A case report Xavier F. Jimenez, M.D. ⁎, Jennifer S. Sharma, M.D., Syma A. Dar, M.D. Cleveland Clinic Foundation, Department of Psychiatry and Psychology, 9500 Euclid Avenue, P57, Cleveland, OH 44195, USA
a r t i c l e
i n f o
Article history: Received 22 May 2014 Revised 27 June 2014 Accepted 30 June 2014 Available online xxxx Keywords: Conversion disorder Psychogenic nonepileptic seizures Cancer Medical stressor
a b s t r a c t Psychogenic nonepileptic seizures (PNES), a form of conversion disorder, are paroxysmal episodes resembling epilepsy while lacking electrographic correlation. The phenomenon has rarely been reported in elderly patients and has not been associated with a new-onset medical diagnosis. We present the case of an 81-year-old female with no past psychiatric or traumatic history who developed PNES within the context of a new, suspected cancer. To our knowledge, this is the first such reported case of a suspected cancer (or otherwise medical) diagnosis contributing directly and temporally to the development of PNES. Discussion of involved psychosocial variables follows the vignette, and a brief review of relevant literature is offered. © 2014 Elsevier Inc. All rights reserved.
1. Introduction Psychogenic nonepileptic seizures (PNES), a form of conversion disorder, are paroxysmal episodes resembling epileptiform seizures while lacking video electroencephalogram (VEEG) correlation [1]. PNES are often diagnosed in young and psychiatrically burdened females; remote and/or ongoing trauma is often implicated, yet acute stressors may be difficult to identify [2]. Various psychiatric reactions to medical illness are possible, including posttraumatic stress disorder [3] and depression with suicidal ideation [4]. There is no literature demonstrating development of PNES upon receiving a new medical diagnosis. We present a case of PNES emerging in the context of a suspected cancer diagnosis in an elderly patient. 2. Clinical vignette Ms. M is an 81-year-old African-American female with a history of stage III kidney disease and chronic, asymptomatic hematologic abnormalities (anemia and thrombocytopenia). She presented to a community hospital with dehydration and diarrhea lasting 5 days, diagnosed with gastroenteritis secondary to food poisoning. Laboratory analysis revealed baseline anemia and thrombocytopenia but no other abnormalities, although some clinical speculation regarding an underlying myelodysplastic process was communicated by the medical teams. On arrival, Ms. M developed frequent, timelimited (under a minute), high-amplitude head-shaking “spells.” Maintaining alertness throughout, she responded to commands ⁎ Corresponding author. E-mail address: [email protected] (X.F. Jimenez).
without subsequent confusion or sensorimotor sequelae. Though less than elaborative, Ms. M was able to describe these as moments of high anxiety but with preserved attention and recollection; she denied linking these to any particular thoughts, feelings or events. Brain magnetic resonance imaging revealed mild, generalized volume loss consistent with age and chronic ischemic microvascular disease but no acute pathology. Bedside electroencephalogram revealed no epileptiform activity or slowing. Psychiatry was consulted; a nonspecific anxiety disorder was offered as a diagnostic possibility, though no specific treatment followed. Upon resolution of gastrointestinal complaints, Ms. M transferred to a nursing facility for physical rehabilitation. While in there, PNES persisted, prompting referral to an epilepsy-monitoring unit (EMU). Psychiatry was re-consulted as numerous typical, consistent episodes occurred, each lacking VEEG correlation. Upon interview, Ms. M was cognitively intact (28/30 on the Mini Mental Status Examination). Although cooperative, she vehemently denied past or current psychiatric illness. Psychosocial history included a “happy childhood” and stable upbringing, lacking any trauma or abuse history. She was married for 40 years until her husband’s death 4 years prior. Since then she lived with her brother and maintained for herself. She cited many other supports, including extended family, friends and her church, and denied legal, military or substance abuse histories. Ms. M also denied financial, relational or legal stressors. When asked if aging had been difficult, she recognized she was “no longer a spring chick” but denied any fear of death. Fleetingly, she did state “the only thing that would stress me out is if I had cancer,” adding that a friend died of cancer in the past. Ms. M’s daughter, very active in her care, corroborated her accounts and baseline presentation; outpatient medical providers were similarly surprised by the PNES.
http://dx.doi.org/10.1016/j.genhosppsych.2014.06.012 0163-8343/© 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Jimenez X.F., et al, Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: A case report, Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.06.012
2
X.F. Jimenez et al. / General Hospital Psychiatry xxx (2014) xxx–xxx
Hematology was consulted to evaluate complete blood counts; they expressed high likelihood of a leukemic process, and a bone marrow biopsy revealed a myeloid neoplasm with increased blasts in bone marrow and peripheral blood suggesting a myeloproliferative neoplasm versus a high-grade myelodysplasia. Prior to this, Ms. M lacked any actual evidence of cancer; of note, at this point, additional history revealed she had missed a recent ambulatory bone marrow biopsy appointment before any of these hospitalizations. After diagnosis, Ms. M manifested no outward distress. She remained optimistic regarding prognosis but continually refused psychiatric follow-up on the grounds that she did not need “mental help” and that her symptoms were “real seizures” despite numerous attempts by both neurologists and psychiatrists at trying to explain conversion disorder as a stress-mediated or psychologically mediated condition. Oncology confirmed a lack of central nervous system cancerous manifestations. She transferred to a rehabilitation facility with subsequent oncological follow-up and persistent PNES episodes.
continually theorized to consist of neurobiological mechanisms, conceptualized by some authors as a parietal “unawareness” syndrome [15]. Despite these perspectives, cases marked by high suspicion of conversion disorder should be declared as such. Nondisclosure of a conversion disorder diagnosis in the hopes of preserving therapeutic alliance has resulted in unintended albeit serious harm [16]. Therapeutic mislabeling [17] sparing psychiatric diagnosis is often seen in neurological evaluations yet should be avoided. As mentioned, elderly patients in particular are at risk for delayed diagnosis of PNES, including iatrogenic harm from unwarranted antiepileptic medication exposure [8]. Future efforts might be directed at increased sensitivity to idiosyncratic or hysterical reactions to medical diagnoses. Considerations include wider use of psychological assessments such as the Minnesota Multiphasic Inventory or the Personality Assessment Inventory in medical populations in order to identify denial, somatization or hysterical patterns [18] perhaps aiding in the diagnosis of conversion disorder or PNES.
3. Discussion In this case, the stressor of a potential cancer diagnosis matched temporally with development of unexplained pseudoneurological symptoms. Interruptible, dramatic, high-amplitude head shaking lasting mere seconds and lacking VEEG correlation strongly suggests psychogenicity. There are no reports of a new suspected medical diagnosis — cancer or otherwise — contributing to or causing PNES. We conducted a search with the following keywords in various combinations: “nonepileptic seizure,” “pseudoseizure,” “conversion disorder,” “conversion reaction,” “medical diagnosis,” “cancer diagnosis,” “cancer” and “medical stressor.” Remarkably, only one [5] published case illustrates conversion symptoms mimicking chemotherapy adverse effects. Others described a functional neurological syndrome in acute lymphocytic leukemia, though symptoms were secondary to the stressor of actual treatment and were confounded by neurotoxic effects of vincristine [6]. Comparably rare are individual reports of conversion disorder beginning anew in the elderly [7,8], though retrospective analyses have shown that 10–17% of patients over 60 years of age admitted to an EMU were diagnosed with PNES [9,10]. Although demographic comparisons between younger and elderly PNES patients have revealed many similarities in regard to trauma history, symptomatology and psychological testing, the elderly have frequently encountered delays in the diagnosis of PNES [11], as analyses have suggested that the elderly more often are diagnosed with physiological (rather than psychogenic) nonepileptic seizures [12,13]. To our knowledge, this is the first report of a suspected medical diagnosis as the stressor resulting in or contributing to electrographically confirmed conversion disorder. We recognize the possibility of underappreciated or minimized histories of trauma or psychiatric illness. Conceptually, it may be that Ms. M’s intolerable cancer fear resulted in defenses of avoidance (missing outpatient oncological evaluation) and denial (superficial interview and history). In a paradoxical manner, PNES may have provided adaptive signaling of distress, forcing comprehensive medical evaluations resulting in an oncological diagnosis. 4. Conclusion Conversion disorder poses diagnostic difficulties, as one cannot confirm the condition with utmost certitude [14]. Furthermore, it is
Disclosures On behalf of all authors, the corresponding author states that there is no conflict of interest.
References [1] LaFrance WC, Reuber M, Goldstein LH. Management of psychogenic nonepileptic seizures. Epilepsia 2013;54(Suppl.1):53–67. [2] Fiszman A, Alves-Leon SV, Nunes RG, D’Andrea I, Figueira I. Traumatic events and posttraumatic stress disorder in patients with psychogenic nonepileptic seizures: a critical review. Epilepsy Behav 2004;5(6):818–25. [3] Bienvenu OJ, Neufeld KJ. Post-traumatic stress disorder in medical settings: focus on the critically ill. Curr Psychiatry Rep 2011;13:3–9. [4] Kishi Y, Robinson RG, Kosier JT. Suicidal ideation among patients with acute lifethreatening physical illness: patients with stroke, traumatic brain injury, myocardial infarction, and spinal cord injury. Psychosomatics 2001;42:382–90. [5] Onishi H, Kamijo A, Onose M, Yamada T, Mizuno Y, Ito M, et al. Conversion disorder with convulsion and motor deficit mimicking the adverse effects of high-dose Ara-C treatment in a posttransplant acute myeloid leukemia patient: a case report and review of the literature. Palliat Support Care 2004;2:79–82. [6] Szajnberg NM, Zalneraitis E, Atlman AJ, Weisman SJ, Andrulonis PA. Atypical anorexia nervosa and hysterical symptomatology in a child with acute lymphocytic leukemia: a case management conference. Clin Pediatr 1989;28 (12):561–6. [7] Fakhoury T, Abou-Khalil B, Newman K. Psychogenic seizures in old age: a case report. Epilepsia 1993;34(6):1049–51. [8] Weddington WW. Conversion reaction in an 82-year-old man. J Nerv Ment Dis 1979;167(6):368–9. [9] Abubakr A, Wambacq I. Seizures in the elderly: video/EEG monitoring analysis. Epilepsy Behav 2005;7:447–50. [10] Behrouz R, Heriaud L, Benbadis SR. Late onset psychogenic nonepileptic seizures. Epilepsy Behav 2006;8:649–50. [11] Acar G, Salinksy MC. Demographic and historical backgrounds of the elderly with nonepileptic seizures: a comparative study. Neurol India 2010;58(1):48–52. [12] McBride AE, Schih TT, Hirsch LJ. Video-EEG monitoring in elderly: a review of 94 patients. Epilepsia 2002;43:165–9. [13] Kellinghaus C, Loddenkemper T, Dinner DS, Lachwani D, Luders HO. Non-epileptic seizures of the elderly. J Neurol 2004;251:704–9. [14] Nicholl JS. Pseudoseizures: a neuropsychiatric diagnostic dilemma. Psychosomatics 1981;22(5):451–4. [15] Perez DL, Barsky AJ, Daffner K, Silbersweig DA. Motor and somatosensory conversion disorder: a functional unawareness syndrome? J Neuropsychiatry Clin Neurosci 2012;24(2):141–51. [16] Kirschner KI, Smith GR, Antiel RM, Lorish P, Frost F, Kanaan RAA. “Doc, why can’t i move?” Ethical dilemmas in treating conversion disorders. PM R 2012;4:296–303. [17] Boissy A, Ford P. A touch of MS: therapeutic mislabeling. Neurology 2012;78 (24):1981–5. [18] Gale SD, Hill SW. Concurrent administration of the MMPI-2 and PAI in a sample of patients with epileptic or non-epileptic seizures: implications for an inpatient epilepsy monitoring unit. Epilepsy Behav 2012;25(2):181–4.
Please cite this article as: Jimenez X.F., et al, Conversion disorder as psychogenic nonepileptic seizures in suspected cancer: A case report, Gen Hosp Psychiatry (2014), http://dx.doi.org/10.1016/j.genhosppsych.2014.06.012