Cases That Test Your Skills

Epilepsy or something else?

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References

Ms. T has a history of mood and behavioral problems since early childhood characterized by episodic dysphoric mood, anxiety, and agitation. She has had trials of several antidepressants, including sertraline, fluoxetine, venlafaxine, and escitalopram, and anxiolytics, including lorazepam, clonazepam, and alprazolam. Her outpatient psychiatrist describes a history of physical and sexual abuse starting at age 7. At age 9, after her mother died from breast cancer, Ms. T and her siblings were moved to foster care, where she was physically abused by the staff. She remained in foster care until age 18.

The authors’ observations

PNES pose a diagnostic and therapeutic challenge. Many PNES patients seek medical attention for their seizures. PNES patients misdiagnosed as having epilepsy have a worse prognosis because they do not receive appropriate treatment9 and may experience side effects if antiepileptics are prescribed.10 Finally, the financial burden of medical care can be significant. Ms. T had several hospitalizations, including extensive neurologic workup, intensive care unit admissions for intubation, and use of antiepileptics with almost no benefit.

Psychosocial assessments of PNES patients have revealed that sexual abuse, family conflicts, and death of a family member often play an important role.11 It is possible that as a result of childhood trauma, Ms. T exhibited a regressed and primitive defense mechanism to deal with the trauma. PNES usually are considered when a patient presents with:

  • absence of therapeutic response to antiepileptics
  • loss of response (therapeutic failure) to antiepileptics
  • paradoxical response to antiepileptics (worsening or unexpected responses)
  • atypical, multiple, or inconsistent seizures
  • seizures that occur soon after emotional stress.12

We concluded Ms. T had PNES because of the unusual presentations of her seizures, negative video EEG findings, failure to respond to antiepileptics, lack of risk factors for epilepsy, and aggressive behaviors before or after the seizures ( Table ).4,10,11,13 Diagnosing PNES early allows clinicians to focus on appropriate treatment modalities (eg, psychotherapy, antidepressants), prevents costly neurologic workups and treatments (eg, routine EEGs, trials of several antiepileptics), and provides patients with diagnostic assurance.10

Table

Characteristics of psychogenic nonepileptic seizures

CharacteristicComment
DurationMay be prolonged
TimingUsually occur only during the day
Physical harmRare
Tongue bitingRare
Urinary incontinenceRare
Motor activityProlonged
CyanosisNo
Postictal confusionRare
Related to medication changesNo
Interictal EEGNormal
Ictal EEGNormal
Presence of secondary gainCommon
EEG: electroencephalography
Source: References 4,10,11,13

3 components of treatment

Presenting the PNES diagnosis to the patient. The neurologist and the psychiatrist should convey to the patient that they see the symptoms as “real” and not “all in your head.”14

Withdrawing antiepileptic medications. Antiepileptic medication withdrawal is recommended when a thorough diagnostic workup shows no evidence of epileptic seizures.15 Oto et al16 reported 49% of PNES patients became seizure-free 12 months after discontinuing antiepileptics.

Psychotherapy and pharmacotherapy. Open-label studies of psychological treatments for PNES have demonstrated that a cognitive-behavioral therapy-based approach and brief augmented psychodynamic interpersonal therapy could reduce seizures.17 In a pilot, randomized, placebo-controlled trial, PNES patients who received flexibly dosed sertraline reported a 45% reduction in seizures compared with an 8% increase in the placebo group.18 Similar improvements in seizure frequency have been reported in PNES patients with anxiety or depression treated with venlafaxine.19

OUTCOME: Support, improvement

During the next several days, Ms. T has random episodes of seizures with foaming of the mouth and unresponsiveness. These episodes last from 5 to 30 minutes and require transfer to the ER. After each episode, Ms. T is medically cleared and sent back to the psychiatric unit. The neurologist recommends avoiding antiepileptics. Ms. T responds well to the structured inpatient setting and supportive psychotherapy. Her episodes decrease and her mood becomes more stable. She refrains from self-injurious behaviors and is discharged home with outpatient follow-up.

Related Resource

  • Marsh P, Benbadis S, Fernandez F. Psychogenic nonepileptic seizures: ways to win over skeptical patients. Current Psychiatry. 2008;7(1):21-35.

Drug Brand Names

  • Alprazolam • Xanax
  • Clonazepam • Klonopin
  • Escitalopram • Lexapro
  • Fluoxetine • Prozac
  • Haloperidol • Haldol
  • Lorazepam • Ativan
  • Quetiapine • Seroquel
  • Sertraline • Zoloft
  • Venlafaxine • Effexor

Disclosure

The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.

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