Psychogenic Non-Epileptic Status as Refractory, Generalized Hypertonic Posturing: Report of Two Adolescents

Abstract

Psychogenic non-epileptic seizures (PNES) or dissociative seizures are found under the umbrella headings of functional/dissociative neurological disorders (FND) in psychiatric classifications (DSM-5; ICD-11). PNES are not characterized by any specific ictal or postictal EEG abnormalities. Patients with PNES can present with motor or non-motor symptoms, frequently associated with a change in the level of consciousness. PNES duration is variable, often longer than that of epileptic seizures. Prolonged PNES, sometimes termed PNES status, involve continuous or repetitive events that exceed 30 min. Prolonged PNES are often misdiagnosed as an epileptic event and are often inappropriately treated with high doses of antiseizure drugs. In this report, we describe two adolescent patients who presented with prolonged PNES characterized by generalized hypertonic posturing and low levels of consciousness. Despite multiple presentation to the Emergency department, and multiple normal video-EEG, the patients were misdiagnosed with epilepsy and were inappropriately treated with antiseizure medications. Both patients presented psychiatric comorbidity, consisting of a major depressive disorder, obsessive-compulsive symptoms, social withdrawal, difficulty of social interaction, and anxious-perfectionist personality traits. The episodes of prolonged PNES gradually declined within 18 months in both patients.

Psychogenic Seizures in Adolescents: An “Evergreen” Diagnostic Challenge

“…Although psychogenic seizures often last longer than epileptic seizures and this feature may be particularly useful for differential diagnosis, some patients with long-lasting events may be misdiagnosed as having epilepsy. This is the case of two adolescent patients (Coppola et al, 2020) with a type of PNES not previously described in the literature, with overlapping symptoms characterized by a significant prolonged state of generalized hypertonic posture with low levels of consciousness, leading to heavy loads of anticonvulsant drugs and occasional endotracheal or endopharyngeal intubation in the emergency room. Both patients had psychiatric comorbidities, including major depressive disorder, obsessivecompulsive symptoms, social withdrawal, difficulty in social interaction, and anxious-perfectionist personality traits.…”