Psychogenic Non-Epileptic Seizures "Redux"

This chapter illustrates a challenge faced by clinicians trying to distinguish between epileptic and psychogenic nonepileptic seizures (PNES): sometimes patients have both and they may occur at different times. A patient was first seen in an epilepsy clinic 10 years ago, when he was 27 years old. He was having daily seizures. These began when he was 21 and had increased in frequency over the past several months, despite treatment with five different AEDs. His phenytoin, valproic acid, and gabapentin were discontinued and he had eight seizures, consisting of altered awareness with "spacey," spinning sensations. Since all his observed episodes were PNES, including a hyperventilation-induced episode, and his EEG was normal, he was not restarted on AEDs. The patient was next seen in the epilepsy clinic 10 years later. He had been seizure free for 4 years and then began having one to two seizures per month. He re-entered counseling for presumed PNES, but his seizures continued. He was diagnosed with Complex partial and secondary generalized epileptic seizures with probable frontal lobe onset. Right hemisphere interictal spikes and a hyperventilation-induced complex partial seizure. Previous psychogenic PNES have behaviors similar to his epileptic seizures. The patient was started on oxcarbazepine at discharge from the epilepsy-monitoring unit. He, however, had several seizures on oxcarbazepine 600 mg BID and was drowsy on 900 mg BID. He was switched to levetiracetam, but had four generalized seizures and was quite irritable. He stopped levetiracetam, was restarted on oxcarbazepine 600 mg TID, and has had no seizures. The chapter also includes further comments on the issues brought up in the case.