Janice, aged 42 years, has been having seizure-like events for the past 4 years, uncontrolled by a series of anti-seizure medication trials. During the seizures her body shakes uncontrollably, her back arches painfully, and she frequently falls. Her surroundings appear blurry, and sounds are muffled or entirely inaudible. Afterwards, her memory of the seizure is patchy and incomplete, and she is sometimes entirely unaware she has had an event.
Janice has been unable to work and is on medical disability from her job as a home health aide. She left a physically abusive relationship 2 years ago and now spends much of her time alone. She has lost interest in visiting with friends and sleeps for much of the day. She attributes her depressed mood and increasing anxiety to the frequent seizures and to her doctors’ failed efforts to treat them.
Prompted by the failure of 5 different anti-seizure medications over 4 years, Janice’s neurologist refers her to a tertiary care epilepsy center. In the epilepsy unit she is continuously monitored with digital video-electroencephalogram (vEEG) and electrocardiogram for 5 days while her anti-seizure medications are withdrawn. Two typical seizure-like events are captured on vEEG, and based on normal brain activity and the clinical appearance on video review, the diagnosis is psychogenic nonepileptic seizures (PNES).
Janice is advised to obtain psychiatric care and given contact information for three psychiatrists: one is not accepting new patients, one did not accept Janice’s Medicaid insurance, and the third offers her an appointment in 6 months. When Janice finally presents for the appointment, she has a seizure in the waiting room, prompting the psychiatrist to summon paramedics who take her to a hospital emergency department. Janice is discharged with instructions to follow up with her neurologist. When she calls the neurologist, he tells her that she does not have a neurological disorder and that she should schedule another appointment with the psychiatrist. When Janice calls the psychiatrist, he tells her that she has a neurological problem and requires further neurological evaluation.
Finally, frustrated by the back and forth, Janice’s primary care physician refers her to a second epilepsy center, where she is again evaluated with vEEG and confirmed to have PNES. This time a neurologist and psychiatrist collaborate and jointly make and communicate to Janice a diagnosis of PNES with comorbid MDD. Venlafaxine is initiated, and Janice is referred to an outpatient psychiatrist and psychotherapist.
Janice receives intensive weekly cognitive-behavioral therapy (CBT) over 4 months. She initially struggles to engage with psychotherapy, and cancels or reschedules nearly half her appointments, but she also recognizes the value of the skills she learns to identify and manage her stress before it builds to the point of a psychogenic attack. She begins to recognize the sadness and fear she still experiences because of the abuse she experienced and develops skills to manage these emotions.
The PNES gradually decrease and finally stop entirely. Her depressive symptoms also improve significantly with venlafaxine and CBT. Janice remains PNES-free and participates in psychotherapy every 2 weeks. She begins working outside the home for the first time in 4 years as a volunteer in an animal shelter.
Dr Tolchin is Assistant Professor, Comprehensive Epilepsy Center, Department of Neurology, Yale University School of Medicine, and Attending Neurologist, Epilepsy Center of Excellence, Neurology Service, VA Connecticut Healthcare System; Dr Altalib is Associate Professor, Department of Neurology, Yale University School of Medicine and Director, Epilepsy Center of Excellence, Neurology Service, VA Connecticut Healthcare System. The authors report no conflicts concerning the subject matter of this article.
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