Monthly Case

Epileptic or dissociative seizure? | 7-2016

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A 35-year-old male patient suffers for more than 10 years from episodes which let him experience an ascending feeling of fear, he then perfoms actions such as holding both hands in front of his face or lashing about with his left arm. During these episodes, he is awake and fully oriented, he answers questions correctly. In general, duration is 5 min. In addition to these paroxysmal episodes with fear, the patient suffers from a chronic generalized anxiety disorder. So far, a clear diagnostic allocation of these episodes to epileptic or dissociative seizures has not been possible. As frequency of these events was two per month, it has not been possible to capture one of these events by video-EEG-monitoring. The generalized anxiety disorder was treated with pregabaline.

Admission to the Department of Epileptology of our institution aimed to correctly diagnose these events. Some days after admission, the patient experienced the stereotyped ascending feeling of fear. He asked one of the nurses to accompany him into his room. There, at first he was very agitated, he expressed solicitude, he grabbed for the water bottle, he turned around, and re rowed in the air with his left arm. At the same time, he was able to adequately communicate with the nurse. This behaviour rather pointed to a dissociative seizure. But approximately 5 min after onset of this episode, he developed tonic posturing of all extremities which after 20 sec evolved into bilateral clonic movements. Due to the unequivocal grand mal seizure at the end of the episode, for the first time it was possible to ascertain the epileptic origin of these episodes. The initial feeling of fear corresponds to an epileptic aura which lasts a couple of minutes and which eventually – and now for the first time – developed into a tonic clonic generalized epileptic seizure. It remains debatable if the movements during the aura are part of the ictal semiology or if they are rather an unconscious reaction to the epileptic fear aura.

After the correct diagnosis of cryptogenic – brain MRI was normal – partial epilepsy was made, we initiated antiepileptic treatment with lamotrigine.

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