Psychogenic nonepileptic seizures (PNES) often manifests with symptoms associated with epileptic seizures as a result of some form of psychological distress as opposed to abnormal brain wave activity. Symptoms may resemble complex partial or absence seizures with atypical movements, falling, reduced attention, or staring. Initially, this disorder is difficult to diagnose, however, it becomes more variable following negative neuroimaging, serial EEG’s, and video EEG monitoring. Approximately 85% of patients suspected of having PNES occur when they have at least 2 normal EEG’s, with at least 2 seizures per week and nontherapeutic response to antiseizure medication. This occurred in this individual, and thus, she was referred for comprehensive neuropsychological consultation.
This case study describes the neuropsychological consequences of a 33-year-old, Caucasian, right-handed female who was diagnosed with psychogenic nonepileptic seizures (PNES). HC is a 33-year-old, Caucasian, married, right-handed female with 13 years of formal education. It was noted that her “seizures” began following a 2-month history of vascular (migraine) headaches. She was evaluated extensively by multiple medical specialists, including her primary care physician, as well as neurology, rheumatology, and ENT. In conjunction with her vascular headaches, HC indicated that she was experiencing significant emotional decompensation secondary to work-related stress. She underwent a cerebral MRI which was negative and nondiagnostic. She was seen at a neurology clinic secondary to vascular headaches and seizure-like activity which was deemed psychogenic in origin. All diagnostic studies, including a cerebral MRI, EEG, cerebral CT scan, and more importantly, video EEG monitoring (September, 2014) were negative and nondiagnostic.
Based on the above noted information, in conjunction with the persistent nature of HC’s symptoms and subjective complaints, she was referred for neuropsychological consultation to aid in developing additional diagnostic impressions and treatment recommendations.
HC’s neuropsychological test results suggested reduced cognitive efficiency and adaptive abilities as evidenced by scores on standardized neuropsychological indices. Primary deficits were in areas of sustained attention/concentration, information processing speed, executive functions, and bilateral UE sensorimotor abilities. Adjustment difficulties, including paranoid delusions and concomitant post-traumatic stress (PTS), contributed to the clinical picture. The etiology for HC’s cognitive decline appears behaviorally mediated. Personality functioning coincides with an agitated depression and an individual with paranoid delusions. The outset of nonepileptic seizures apparently culminated from the combination of general life and work stressors. Her diagnosis of PNES appeared reasonable especially following the extensive neurological work up which included negative neurodiagnostics including a cerebral MRI, EEG, CT scan, and VEEG monitoring. In conclusion, nonepileptic seizures are often a primary manifestation of psychological distress.
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Michael J. Raymond, Ph.D., ABN, FACPN
Board Certified Neuropsychologist #232
Licensed Psychologist #35S100252900