Psychogenic Nonepileptic Events

Case study #3. S. L. was a 24-year-old woman who had the onset of spells at 22 years of age. Episodes were characterized by a headache and tired feeling, followed by loss of consciousness and jerking movements of the trunk and extremities. Loss of consciousness lasted up to 5 min. The patient reported that incontinence occurred rarely. The frequency of episodes varied from one per week at the onset of her illness, to one per day at the time of referral. She was treated with phenytoin, gabapentin, and lamotrigine without control. Etiological factors included a motor vehicle accident that resulted in less than 5 min of impaired consciousness just prior to the onset of events. There were no neurological sequelae following the accident. The examination was normal.

Magnetic resonance imaging (MRI) studies were normal. An interictal EEG showed right anterior temporal slowing. No interictal epilepti-form discharges occurred during the awake and sleep states, and there were no epileptiform discharges during a recording obtained following a night of sleep deprivation.

During video-EEG monitoring, one episode occurred. The episode began with recurrent adduction movements of both lower extremities. These began as limited movements occurring at a frequency of approximately one per second. These movements gradually increased in amplitude and frequency over a 10-second period. The adduction movements were followed by extension of the back and hyperkinetic movements of the trunk. Simultaneous with the hyperkinetic movements were alternating flexion/extension movements at the elbow and abduction/adduction movements at the shoulders; these movements were asymmetric between the two sides. Approximately 25 seconds after onset, the motor activity suddenly stopped, and the patient relaxed. The patient did not respond to the nurse for several minutes after the cessation of motor activity. On attempted eye opening at this time, there was forced closure of the eyes.

During the motor activity, the EEG was obscured by muscle and movement artifact. Prior to the onset of the motor activity and immediately following its cessation, the EEG was normal with a well-developed alpha rhythm. The EEG remained normal during the entire period of unre-sponsiveness. Based on the normal EEG during apparent impaired consciousness, as well as the fact that the motor phenomena did not fit a characteristic epileptic pattern, a diagnosis of psy-chogenic nonepileptic event was made.

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