Cases That Test Your Skills

Epilepsy or something else?

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Ms. T, age 20, has a history of trauma and mood problems. She has seizure-like episodes but EEG and other tests do not find a cause. How would you treat her?


 

References

CASE: Seizure-like symptoms

Ms. T, age 20, is brought to the emergency room (ER) by her father because she refuses to eat and drink, is unable to function at home, lies in bed all day, and does not attend to her activities of daily living (ADLs). Ms. T lives with her family, is not enrolled in school, and is unemployed. In the ER she initially is uncooperative and mute and then suddenly becomes agitated and has a seizure-like episode characterized by jerking of her trunk followed by random, asymmetrical movements of her legs and arms, closing both eyes, weeping, foaming at the mouth, moaning, and marked unresponsiveness. The episode lasts for >5 minutes.

The authors’ observations

Based on Ms. T’s presentation, the medical team considered acute epileptic seizures. Asymmetrical jerking of the body may be seen in frontal lobe epilepsy or seizures of the supplementary sensorimotor area. Frontal lobe epilepsy can present with bilateral asynchronous motor activity with consciousness during the event and a lack of postictal confusion.1 Seizures of the supplementary sensorimotor area—also known as the secondary motor area—are particularly problematic because typically they present with bilateral asymmetric tonic posturing followed by a few clonic movements, intact consciousness, and rarely postictal confusion. Adding to the diagnostic uncertainty, some “soft signs” thought to indicate PNES (eg, pelvic thrusting, crying) are common with frontal lobe epilepsy.1,2

PNES are episodes of altered movement, sensation, or experience that may be mistaken for epileptic seizures but are not a consequence of abnormal cortical discharges. Instead they are caused by physiological or psychological factors.3 Behaviors or signs that strongly suggest PNES include:

  • gradual onset or termination
  • pseudosleep, when the patient appears to be asleep but electroencephalography (EEG) findings indicate he or she is awake
  • discontinuous (stop-and-go), irregular, or asynchronous (out-of-phase) activity—including side-to-side head movement, pelvic thrusting, and opisthotonic posturing—stuttering, and weeping4
  • eye closure.5

Ms. T’s father said his daughter had been hospitalized several times for episodes characterized by pelvic thrusting, stuttering, and pseudosleep, which raised the possibility of PNES. Definitive diagnosis of PNES comes from video EEG when a patient is observed having typical seizures without accompanying EEG abnormalities.6

EVALUATION: Inconclusive data

Ms. T is admitted to the medical unit to rule out a seizure disorder. Physical examination is unremarkable and laboratory tests are within normal limits. The neurology service requests a head MRI, which is inconclusive. Inpatient video EEG with 24-hour monitoring does not indicate acute epileptic seizures. Ms. T’s father says that she has experienced many paroxysmal motor episodes and all neurologic tests, exams, and labs have failed to find a cause for these episodes. She did not receive any antiepileptic medications. A psychiatric consult is requested to clarify the diagnosis. Ms. T is transferred to an inpatient psychiatric unit for further evaluation and management.

The authors’ observations

Fleisher et al7 suggested that traumatic events may lead to presentations similar to PNES. Because Ms. T was molested by a family friend as a child, we considered posttraumatic stress disorder (PTSD) in the differential diagnosis, although she has not reported symptoms of intrusive recollections, avoidance, numbing, or hyperarousal.

We also considered conversion disorder and dissociative disorder. Patients with conversion disorder have ≥1 symptoms or signs that affect voluntary motor or sensory function that cannot be explained by a neurologic or general medical condition.8 Dissociative disorder is a disruption in usually integrated functions of consciousness, memory, identity, or perception of the environment.8 The presentation of patients with PNES may resemble that of patients with dissociative disorder.8 In a study of 45 adult PNES patients, Bowman et al8 found that PNES often are comorbid with other psychiatric disorders, including somatoform disorders (89%), dissociative disorders (91%), affective disorders (64%), personality disorders (62%), PTSD (49%), and other anxiety disorders (47%).

TREATMENT: Managing aggression

In the psychiatric unit, Ms. T initially is irritable and disorganized with poor oral intake and regressed behavior; she often is found in the fetal position, crying and talking in a childish manner. Throughout her admission, she receives several anxiolytics and antipsychotics—including lorazepam, up to 6 mg/d, clonazepam, up to 3 mg/d, haloperidol, up to 10 mg/d, and quetiapine, up to 200 mg/d—to help manage her aggressive behaviors after her seizure-like episodes. Further evaluation reveals that Ms. T has no psychotic symptoms, overt delusions, or perceptual disturbances and her thought process is coherent and clear. She has no history of substance abuse. Her ability to perform ADLs improves within a few days. She complains of depressed mood and engages in head banging, which requires close observation.

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