Batool F Kirmani

J L González-Gutiérrez

R Koide

T K Banerjee

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Hindawi Publishing Corporation
Case Reports in Neurological Medicine
Volume 2013, Article ID 159842, 2 pages
http://dx.doi.org/10.1155/2013/159842
Case Report
Importance of Video-EEG Monitoring in the Diagnosis of
Epilepsy in a Psychiatric Patient
Batool F. Kirmani
Epilepsy Center, Department of Neurology, Scott & White Neuroscience Institute and Texas A&M Health Science Center
College of Medicine, Temple, TX 76508, USA
Correspondence should be addressed to Batool F. Kirmani; bkirmani@swmail.sw.org
Received 2 February 2013; Accepted 4 March 2013
Academic Editors: T. K. Banerjee, J. L. González-Gutiérrez, and R. Koide
Copyright © 2013 Batool F. Kirmani. This is an open access article distributed under the Creative Commons Attribution License,
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
Epilepsy is a chronic medical condition which is disabling to both patients and caregivers. The differential diagnosis of epilepsy
includes psychogenic nonepileptic spells or “pseudoseizures.” Epilepsy is due to abnormal electrical activity in the brain, and
pseudoseizure is a form of conversion disorder. The brain waves remain normal in pseudoseizures. The problem arises when a
patient with significant psychiatric history presents with seizures. Pseudoseizures become high on the differential diagnosis without
extensive work up. This is a case of woman with significant psychiatric issues which resulted in a delay in the diagnosis of epilepsy.
1. Case Report
Ms. V is a 33-year-old married right-handed Caucasian
woman with history of questionable spells characterized by
loss of consciousness and whole body jerking since the age of
13. She had several EEGs in the past which were normal. She
has a history of significant anxiety issues including depression
and behavioral problems. She attributes most of her prob-
lems to childhood abuse. There have been instances in the
emergency room where there has been a delay in treatment
because of high suspicion of pseudoseizures. Her first episode
of generalized body jerking was at the age of 13, with a
second episode one year later. She was initially prescribed
Dilantin and then phenobarbital by a local physician. She
could not tolerate these medications and continued to be
intractable.The EEGs were also negative. However, she never
had a prolonged EEG under medication withdrawal where
the spell was actually captured. She was started on Depakote
at age 14, which did improve the spells but it was tapered
off because of weight gain. She was switched to Topamax
with no effective control. She was on a combination of
Tegretol and Lamictal for a year when she was seen in our
epilepsy clinic. She was having several spells with associ-
ated injuries and at least 1-2 emergency room visits every
month or every other month. She also had isolated auras of
deja vu sensation at least twice a week, which lasted for about
a minute without any alteration of consciousness. She denies
any family history of epilepsy, febrile seizures, TIA, stroke,
or meningitis. She has had an abusive childhood and has
had several domestic issues going on with her children and
siblings. Her examination was completely normal. She was
admitted to the epilepsy monitoring unit in order to capture
her spells for definitive diagnosis. Lamictal and Tegretol
were withdrawn but unfortunately no spells were captured
and her EEG was normal. Based on the description of the
spells, she was discharged on Lamictal and Keppra. Tegretol
was discontinued during this stay. She continued to have
breakthrough spells and Keppra aggravated the mood issues.
There was always a bias in terms of her psychiatric history
that she may be having pseudoseizures. She was brought
again to the epilepsy monitoring unit a few months later to
capture her spells. Lamictal andKepprawerewithheld the day
of admission. She had one spell lasting for 2 minutes charac-
terized by whole body jerking and loss of consciousness.This
was associated with a generalized spike and wave discharge
consistent with generalized epilepsy. She was restarted on
Depakote for generalized epilepsy and mood disorder since
she had had a favorable trial in terms of spells. She has been
essentially seizure free for the last 2 years with occasional
breakthrough if she forgets to take her medication.
2 Case Reports in Neurological Medicine
This case report emphasizes the need for specialized
testing when establishing a diagnosis. In this case, it took
almost two decades for an accurate diagnosis of generalized
epilepsy to be made. Seizures are due to hyperactivity of
the cortical neurons or synchronous neuronal activity in
the brain [1]. In primary generalized epilepsy, the abnor-
mal electrical activity starts simultaneously from both the
right and the left cerebral hemispheres [2]. The diagnosis
of epilepsy includes a careful history and EEG findings.
Her history was consistent with generalized epilepsy. She
does have auras which are commonly considered a part
of localization related to epilepsy. However, it has been
shown in the literature that 70% of patients with generalized
epilepsy also have auras [3]. It has been shown that patients
with epilepsy do have other psychiatric comorbidities. The
most common psychiatric conditions in epilepsy are anxiety,
depression, and psychoses [4]. So epilepsy should not be
excluded in these subsets of patients. Pseudoseizures are also
high on the differential diagnosis because of her abusive
childhood and stressful life but should not be considered as
the primary diagnosis. Pseudoseizures fall under the category
of somatoform disorders according to the Diagnostic and
Statistical Manual of Mental Diseases. Somatoform disorders
involve unconscious manifestation of the physical symptoms
due to internal issues, which the patient is unable to express.
These physical symptoms produced by the patient are not
under voluntary control. The main focus of this paper is to
establish diagnosis in order to find the right treatment for
these patients and to avoid medicines which decrease the
seizure threshold.Our patientwas started onDepakotewhich
provides good seizure control against generalized epilepsy
and also works well with psychiatric comorbidities [5].
Conflict of Interests
The authors have no conflict of interest to disclose.There was
no funding.
References
[1] R. S. Fisher, W. van Emde Boas, W. Blume et al., “Epileptic
seizures and epilepsy: definitions proposed by the International
League Against Epilepsy (ILAE) and the International Bureau
for Epilepsy (IBE),” Epilepsia, vol. 46, no. 4, pp. 470–472, 2005.
[2] J. Bancaud, O. Henriksen, F. Rubio-Donnadieu, M. Seino, F.
E. Dreifuss, and J. K. Penry, “Proposal for revised clinical
and electroencephalographic classification of epileptic seizures.
From theCommission onClassification andTerminology of the
International League Against Epilepsy,” Epilepsia, vol. 22, no. 4,
pp. 489–501, 1981.
[3] L. S. Boylan, D. L. Labovitz, S. C. Jackson, K. Starner, and
O. Devinsky, “Auras are frequent in idiopathic generalized
epilepsy,” Neurology, vol. 67, no. 2, pp. 343–345, 2006.
[4] R. Torta and R. Keller, “Behavioral, psychotic, and anxiety
disorders in epilepsy: etiology, clinical features, and therapeutic
implications,” Epilepsia, vol. 40, supplement 10, pp. S2–S20,
1999.
[5] S. Cutting, A. Lauchheimer, W. Barr, and O. Devinsky, “Adult-
onset idiopathic generalized epilepsy: clinical and behavioral
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Case Report Importance of Video-EEG Monitoring in the Diagnosis of Epilepsy in a Psychiatric Patient

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Case Report Importance of Video-EEG Monitoring in the Diagnosis of Epilepsy in a Psychiatric Patient

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