Paeds Cases · neurology-neurodisability-and-neuromuscular
Non-epileptic events and functional seizures — structured clinical encounter
Structured encounter testing the approach to a fifteen-year-old girl referred for daily spells unresponsive to two escalating antiseizure drugs: the recognition of the semiology of a functional seizure, the positive confirmation by video-electroencephalogram, the management of coexisting epilepsy, and the leadership of the explanation, supervised drug withdrawal and cognitive behavioural therapy pathway.
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Target exams
Task 1 — Recognise the functional seizure (3 minutes)
Working from the eyewitness account and the examination, explain which features confirm that these attacks are functional (dissociative) seizures rather than epileptic seizures or a physiological mimic, and state why no single feature alone is sufficient to make the diagnosis. [1]
Task 2 — Confirm the diagnosis positively (4 minutes)
Describe the investigation that confirms a functional seizure, how it is performed, and what it must demonstrate. Explain why a normal interictal electroencephalogram is not diagnostic, what the place of prolactin is in modern practice, and how you would resolve the possibility of frontal-lobe epilepsy with bizarre brief attacks. [1] [8]
Task 3 — Lead the explanation and the drug withdrawal (4 minutes)
Describe the conversation you would have with the girl and her mother to deliver the diagnosis, and explain why a good explanation is itself therapeutic. Outline how you would withdraw the two unnecessary antiseizure medications, the principle that governs this, and the safety-netting you would provide during the taper. [3] [5]
Task 4 — The pathway to recovery and the safeguarding history (4 minutes)
Outline the psychological therapy and multidisciplinary rehabilitation you would arrange, naming the first-line treatment and the evidence that supports it. Describe the psychosocial and trauma history you would take and the safeguarding considerations raised by the family breakdown and missed schooling, and state how you would support her return to school. [10] [2]
References
- [1]Leibetseder A; Eisermann M; LaFrance WC Jr; et al How to distinguish seizures from non-epileptic manifestations Epileptic Disord, 2020.PMID 33399092
- [2]Doss JL; Robinson JO; et al Psychogenic non-epileptic seizures in youth: Individual and family psychiatric characteristics Front Psychiatry, 2022.PMID 36590633
- [3]Gasparini S; Beghi E; Ferlazzo E; et al Management of psychogenic non-epileptic seizures: a multidisciplinary approach Eur J Neurol, 2019.PMID 30300463
- [4]Espay AJ; Aybek S; Carson A; et al Current Concepts in Diagnosis and Treatment of Functional Neurological Disorders JAMA Neurol, 2018.PMID 29868890
- [5]Lopez MR; LaFrance WC Jr Treatment of Psychogenic Nonepileptic Seizures Curr Neurol Neurosci Rep, 2022.PMID 35674871
- [6]Hallett M; Aybek S; Dworetzky BA; et al Functional neurological disorder: new subtypes and shared mechanisms Lancet Neurol, 2022.PMID 35430029
- [7]Patel H; Blake H; Dunn D Psychogenic Nonepileptic Seizures in Children and Adolescents Indian Pediatr, 2021.PMID 33713062
- [8]Albert DVF; Voeller K; et al Psychogenic Nonepileptic Seizures in Children and Adolescents Semin Pediatr Neurol, 2022.PMID 35450667
- [9]LaFrance WC Jr; Baird GL; Barry JJ; et al Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial JAMA Psychiatry, 2014.PMID 24989152
- [10]Goldstein LH; Robinson EJ; Mellers JDC; et al Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial Lancet Psychiatry, 2020.PMID 32445688
- [11]Spiegel D; Lewis-Fernandez R; Lanius R; et al Dissociative disorders in DSM-5 Annu Rev Clin Psychol, 2013.PMID 23394228
- [12]Hamed SA; Attiah FA; Fawzy M Psychogenic nonepileptic seizures in adults with epilepsy: a tertiary hospital-based study Int J Neurosci, 2020.PMID 31771384