Intubation in a Case of Psychogenic, Non-Epileptic Status Epilepticus

A 43-year-old Hispanic man was admitted to Neurology for evaluation of progressive, “vice-like” headache in the bilateral parietal area. Over the course of the day, he was noticed to have “intermittent twitching” of the left eye, followed by shaking of both lower extremities. Over a period of hours, this increased in intensity and spread to the upper extremities. This did not respond to IV lorazepam and midazolam. He was transferred to the ICU. Phenytoin loading and levetiracetam were commenced. Despite this, the patient continued to display abnormal movements and was intubated for “airway protection.”

Electroencephalography (EEG) did not reveal any epileptiform activity. CT of the head and mri of the brain did not show any abnormalities. CBC, CMP, and UA were within normal limits, and the drug screen was negative. After extubation, the patient began to gradually exhibit similar movements. Video EEG confirmed the lack of epileptiform activity. There was no history of seizure disorder or previous contact with psychiatric services. The week before hospital admission, he discovered that his separated wife was moving to a new town, along with their daughter.

PNES are “paroxysmal motor events, disturbances of sensation or of responsiveness” that occur in the absence of abnormal brain electrical activity. PNES is usually characterized by “excessive movements of the limbs, trunk, and head,” with an apparent change in consciousness.¹ In the DSM-IV-TR, they are classified under Somatoform Disorders in the Conversion Disorder category, using the specifier “with seizures or convulsions.” Although PNES remains the preferred term, several synonyms, such as non-epileptic seizures, pseudoseizures, and psychogenic seizures, have been used in the literature.² Prevalence of PNES is estimated to be 1.4–3 per 100,000 in the general population, 5%–33% among outpatient epilepsy clinics, and 10%–58% in patients admitted for refractory epilepsy. Women account for nearly 80% of PNES cases.³ The duration of PNES can vary from less than 1 minute to more than 150 minutes. The term “psychogenic non-epileptic status epilepticus” is used for PNES with extended duration. Several clinical signs help to distinguish PNES from epileptic seizures (ES). PNES is characterized by fluctuating course (brief pauses, “waxing and waning”), asynchronous motor activity, pelvic thrusting, closed eyes, and “ictal crying.”¹ Video EEG is the gold standard test for distinguishing PNES from ES. Psychological factors such as childhood abuse, borderline personality traits, and previous history of dissociative or somatoform disorders are associated with PNES. Many patients with PNES also exhibit symptoms of posttraumatic stress disorder (PTSD). PNES is also seen more commonly in patients with personal or family history of epilepsy and in someone who has previously witnessed a seizure.⁴ There are no guidelines for treatment of PNES, but educating the patient and family that recent episodes were PNES and not ES and identification and treatment of psychological factors play an important role in improving overall prognosis.²