Epilepsy Or Something Else? Dimitry Francois, MD, Smita Agarkar, MD, and Nabil Kotbi, MD

Cases That Test Your Skills

Epilepsy or something else? Dimitry Francois, MD, Smita Agarkar, MD, and Nabil Kotbi, MD

How would you Ms. T, age 20, has a history of trauma and mood problems. She handle this case? has seizure-like episodes but EEG and other tests do not find a Visit CurrentPsychiatry.com to input your answers cause. How would you treat her? and see how your colleagues responded

CASE Seizure-like symptoms mentary sensorimotor area—also known as Ms. T, age 20, is brought to the emergency the secondary motor area—are particularly room (ER) by her father because she refuses to problematic because typically they present eat and drink, is unable to function at home, lies with bilateral asymmetric tonic posturing in bed all day, and does not attend to her ac- followed by a few clonic movements, intact tivities of daily living (ADLs). Ms. T lives with her consciousness, and rarely postictal confu- family, is not enrolled in school, and is unem- sion. Adding to the diagnostic uncertainty, ployed. In the ER she initially is uncooperative some “soft signs” thought to indicate PNES and mute and then suddenly becomes agitated (eg, pelvic thrusting, crying) are common and has a seizure-like episode characterized by with frontal lobe epilepsy.1,2 jerking of her trunk followed by random, asym- PNES are episodes of altered move- metrical movements of her legs and arms, clos- ment, sensation, or experience that may ing both eyes, weeping, foaming at the mouth, be mistaken for epileptic seizures but are moaning, and marked unresponsiveness. The not a consequence of abnormal cortical episode lasts for >5 minutes. discharges. Instead they are caused by physiological or psychological factors.3 What is your differential diagnosis? Behaviors or signs that strongly suggest a) acute epileptic seizures PNES include: b) psychogenic nonepileptic seizures (PNES) • gradual onset or termination c) conversion disorder • pseudosleep, when the patient ap- d) dissociative disorder pears to be asleep but electroencephalography (EEG) findings indicate he or she is The authors’ observations awake Based on Ms. T’s presentation, the medical • discontinuous (stop-and-go), irregu- team considered acute epileptic seizures. lar, or asynchronous (out-of-phase) activ- Asymmetrical jerking of the body may be ity—including side-to-side head move- seen in frontal lobe epilepsy or seizures ment, pelvic thrusting, and opisthotonic of the supplementary sensorimotor area. posturing—stuttering, and weeping4 Frontal lobe epilepsy can present with bi- • eye closure.5 lateral asynchronous motor activity with consciousness during the event and a lack of Dr. Francois is Instructor in Psychiatry, Dr. Agarkar is Assistant Current Psychiatry Professor of Psychiatry, and Dr. Kotbi is Assistant Professor of 46 September 2012 postictal confusion.1 Seizures of the supple- Psychiatry, Weill Cornell Medical College, White Plains, NY. Cases That Test Your Skills

Ms. T’s father said his daughter had been PNES patients, Bowman et al8 found that hospitalized several times for episodes PNES often are comorbid with other psy- characterized by pelvic thrusting, stutter- chiatric disorders, including somatoform ing, and pseudosleep, which raised the disorders (89%), dissociative disorders possibility of PNES. Definitive diagnosis (91%), affective disorders (64%), personal- of PNES comes from video EEG when a ity disorders (62%), PTSD (49%), and other patient is observed having typical seizures anxiety disorders (47%). without accompanying EEG abnormalities.6 How would you manage Ms. T? a) start an antiepileptic medication EVALUATION Inconclusive data b) explore her history of trauma and sexual Ms. T is admitted to the medical unit to rule abuse out a seizure disorder. Physical examination is c) begin insight-oriented psychodynamic Clinical Point unremarkable and laboratory tests are within psychotherapy normal limits. The neurology service requests PNES often are a head MRI, which is inconclusive. Inpatient comorbid with video EEG with 24-hour monitoring does not TREATMENT Managing aggression somatoform, indicate acute epileptic seizures. Ms. T’s father In the psychiatric unit, Ms. T initially is irritable dissociative, affective, says that she has experienced many paroxys- and disorganized with poor oral intake and re- personality, or mal motor episodes and all neurologic tests, gressed behavior; she often is found in the fetal exams, and labs have failed to find a cause for position, crying and talking in a childish man- anxiety disorders these episodes. She did not receive any anti- ner. Throughout her admission, she receives epileptic medications. A psychiatric consult several anxiolytics and antipsychotics—includ- is requested to clarify the diagnosis. Ms. T is ing lorazepam, up to 6 mg/d, clonazepam, up transferred to an inpatient psychiatric unit for to 3 mg/d, haloperidol, up to 10 mg/d, and further evaluation and management. quetiapine, up to 200 mg/d—to help manage her aggressive behaviors after her seizure-like The authors’ observations episodes. Further evaluation reveals that Ms. T Fleisher et al7 suggested that traumatic has no psychotic symptoms, overt delusions, or events may lead to presentations similar perceptual disturbances and her thought pro- to PNES. Because Ms. T was molested by cess is coherent and clear. She has no history of a family friend as a child, we considered substance abuse. Her ability to perform ADLs posttraumatic stress disorder (PTSD) in the improves within a few days. She complains of differential diagnosis, although she has not depressed mood and engages in head bang- reported symptoms of intrusive recollec- ing, which requires close observation. tions, avoidance, numbing, or hyperarousal. Ms. T has a history of mood and behavioral We also considered conversion disorder problems since early childhood characterized by and dissociative disorder. Patients with episodic dysphoric mood, anxiety, and agitation. conversion disorder have ≥1 symptoms or She has had trials of several antidepressants, in- signs that affect voluntary motor or sen- cluding sertraline, fluoxetine, venlafaxine, and sory function that cannot be explained by escitalopram, and anxiolytics, including loraz- Discuss this article at a neurologic or general medical condition.8 epam, clonazepam, and alprazolam. Her outpa- www.facebook.com/ Dissociative disorder is a disruption in usu- tient psychiatrist describes a history of physical CurrentPsychiatry ally integrated functions of consciousness, and sexual abuse starting at age 7. At age 9, after memory, identity, or perception of the envi- her mother died from breast cancer, Ms. T and ronment.8 The presentation of patients with her siblings were moved to foster care, where PNES may resemble that of patients with she was physically abused by the staff. She re- Current Psychiatry dissociative disorder.8 In a study of 45 adult mained in foster care until age 18. Vol. 11, No. 9 47 continued Cases That Test Your Skills

Table • absence of therapeutic response to antiepileptics Characteristics of psychogenic • loss of response (therapeutic failure) nonepileptic seizures to antiepileptics Characteristic Comment • paradoxical response to antiepileptics Duration May be prolonged (worsening or unexpected responses) Timing Usually occur only • atypical, multiple, or inconsistent during the day seizures Physical harm Rare • seizures that occur soon after emo- Tongue biting Rare tional stress.12 Urinary incontinence Rare We concluded Ms. T had PNES because Motor activity Prolonged of the unusual presentations of her sei- Clinical Point Cyanosis No zures, negative video EEG findings, failure Postictal confusion Rare to respond to antiepileptics, lack of risk fac- Sexual abuse, Related to medication No tors for epilepsy, and aggressive behaviors family conflicts, and changes before or after the seizures (Table).4,10,11,13 death of a family Interictal EEG Normal Diagnosing PNES early allows clinicians member often play Ictal EEG Normal to focus on appropriate treatment modali- Presence Common ties (eg, psychotherapy, antidepressants), an important role in of secondary gain prevents costly neurologic workups and PNES EEG: electroencephalography treatments (eg, routine EEGs, trials of sev- Source: References 4,10,11,13 eral antiepileptics), and provides patients with diagnostic assurance.10

The authors’ observations PNES pose a diagnostic and therapeu- 3 components of treatment tic challenge. Many PNES patients seek Presenting the PNES diagnosis to the medical attention for their seizures. PNES patient. The neurologist and the psychia- patients misdiagnosed as having epilepsy trist should convey to the patient that they have a worse prognosis because they do see the symptoms as “real” and not “all in not receive appropriate treatment9 and your head.”14 may experience side effects if antiepileptics are prescribed.10 Finally, the financial Withdrawing antiepileptic medications. burden of medical care can be signifi- Antiepileptic medication withdrawal is cant. Ms. T had several hospitalizations, recommended when a thorough diagnos- including extensive neurologic workup, tic workup shows no evidence of epileptic intensive care unit admissions for intuba- seizures.15 Oto et al16 reported 49% of PNES tion, and use of antiepileptics with almost patients became seizure-free 12 months after no benefit. discontinuing antiepileptics. Psychosocial assessments of PNES patients have revealed that sexual abuse, Psychotherapy and pharmacotherapy. family conflicts, and death of a family Open-label studies of psychological treat- member often play an important role.11 It ments for PNES have demonstrated that is possible that as a result of childhood a cognitive-behavioral therapy-based ap- trauma, Ms. T exhibited a regressed and proach and brief augmented psychody- primitive defense mechanism to deal with namic interpersonal therapy could reduce the trauma. PNES usually are considered seizures.17 In a pilot, randomized, placebo- Current Psychiatry 48 September 2012 when a patient presents with: controlled trial, PNES patients who received continued on page 50 Cases That Test Your Skills

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2. Kanner AM, Morris HH, Lüders H, et al. Supplementary motor seizures mimicking pseudoseizures: some clinical Related Resource differences. Neurology. 1990;40(9):1404-1407. • Marsh P, Benbadis S, Fernandez F. Psychogenic nonepileptic 3. Hall-Patch L, Brown R, House A, et al. Acceptability and seizures: ways to win over skeptical patients. Current Psychiatry. effectiveness of a strategy for the communication of the 2008;7(1):21-35. diagnosis of psychogenic nonepileptic seizures. Epilepsia. 2010;51(1):70-78. Drug Brand Names 4. Reuber M, Elger CE. Psychogenic nonepileptic seizures: Alprazolam • Xanax Lorazepam • Ativan review and update. Epilepsy Behav. 2003;4(3):205-216. Clonazepam • Klonopin Quetiapine • Seroquel 5. Chung SS, Gerber P, Kirlin KA. Ictal eye closure is a reliable Escitalopram • Lexapro Sertraline • Zoloft indicator for psychogenic nonepileptic seizures. Neurology. Fluoxetine • Prozac Venlafaxine • Effexor 2006;66(11):1730-1731. Haloperidol • Haldol 6. Mostacci B, Bisulli F, Alvisi L, et al. Ictal characteristics of psychogenic nonepileptic seizures: what we have learned Disclosure from video/EEG recordings--a literature review. Epilepsy The authors report no financial relationship with any company Behav. 2011;22(2):144-153. whose products are mentioned in this article or with manufactur- 7. Fleisher W, Staley D, Krawetz P, et al. Comparative study of ers of competing products. trauma-related phenomena in subjects with pseudoseizures and subjects with epilepsy. Am J Psychiatry. 2002;159(4): Clinical Point 660-663. 8. Bowman ES, Markand ON. Psychodynamics and psychiatric diagnoses of pseudoseizure subjects. Am J A cognitive- Psychiatry. 1996;153(1):57-63. behavioral therapy- 9. Benbadis SR. The EEG in nonepileptic seizures. J Clin flexibly dosed sertraline reported a 45% re- Neurophysiol. 2006;23(4):340-352. based approach and duction in seizures compared with an 8% 10. Brown RJ, Syed TU, Benbadis S, et al. Psychogenic increase in the placebo group.18 Similar im- nonepileptic seizures. Epilepsy Behav. 2011;22(1):85-93. brief augmented 11. Bodde NM, Brooks JL, Baker GA, et al. Psychogenic non- provements in seizure frequency have been epileptic seizures--definition, etiology, treatment and psychodynamic prognostic issues: a critical review. Seizure. 2009;18(8): reported in PNES patients with anxiety or 543-553. interpersonal therapy 19 depression treated with venlafaxine. 12. Alsaadi TM, Marquez AV. Psychogenic nonepileptic could reduce PNES seizures. Am Fam Physician. 2005;72(5):849-856. 13. Bradley WG, Daroff RB, Fenichel GM, et al, eds. Neurology in clinical practice: principles of diagnosis and management. OUTCOME 4th ed. Philadelphia, PA: Butterworth Heinemann; 2004:19- Support, improvement 20, 1971-1972. During the next several days, Ms. T has random 14. Harden CL, Ferrando SJ. Delivering the diagnosis of psychogenic pseudoseizures: should the neurologist or episodes of seizures with foaming of the mouth the psychiatrist be responsible? Epilepsy Behav. 2001;2(6): and unresponsiveness. These episodes last from 519-523. 15. Oto M, Espie CA, Duncan R. An exploratory randomized 5 to 30 minutes and require transfer to the ER. controlled trial of immediate versus delayed withdrawal of antiepileptic drugs in patients with psychogenic After each episode, Ms. T is medically cleared and nonepileptic attacks (PNEAs). Epilepsia. 2010;51(10): sent back to the psychiatric unit. The neurologist 1994-1999. 16. Oto M, Espie C, Pelosi A, et al. The safety of antiepileptic recommends avoiding antiepileptics. Ms. T re- drug withdrawal in patients with non-epileptic seizures. sponds well to the structured inpatient setting J Neurol Neurosurg Psychiatry. 2005;76(12):1682-1685. 17. Goldstein LH, Mellers JD. Recent developments in and supportive psychotherapy. Her episodes our understanding of the semiology and treatment of decrease and her mood becomes more stable. psychogenic nonepileptic seizures. Curr Neurol Neurosci Rep. 2012;12(4):436-444. She refrains from self-injurious behaviors and is 18. LaFrance WC Jr, Keitner GI, Papandonatos GD, et al. Pilot discharged home with outpatient follow-up. pharmacologic randomized controlled trial for psychogenic nonepileptic seizures. Neurology. 2010;75(13):1166-1173. 19. Pintor L, Baillés E, Matrai S, et al. Efficiency of venlafaxine References in patients with psychogenic nonepileptic seizures and 1. Kellinghaus C, Lüders HO. Frontal lobe epilepsy. anxiety and/or depressive disorders. J Neuropsychiatry Epileptic Disord. 2004;6(4):223-239. Clin Neurosci. 2010;22(4):401-408.

Bottom Line Psychogenic nonepileptic seizures resemble epileptic seizures but are caused by psychological distress. They often are comorbid with other psychiatric disorders, including somatoform, dissociative, affective, or anxiety disorders. Patients may Current Psychiatry 50 September 2012 respond to supportive psychotherapy and antidepressants.