A 20-year-old college student comes to the emergency department accompanied by her roommate after an episode of falling to the ground and "shaking all over." Her roommate was able to record part of the episode on her phone, which shows the patient lying on the ground, rhythmically shaking all 4 extremities, and tightly closing her eyes. The roommate is heard asking multiple questions but the patient remains nonresponsive. The episode resolves within 1 minute, when the patient gets up and asks her roommate to take her to the emergency department. The patient has been studying for upcoming final exams, has had minimal sleep, and has consumed multiple cups of coffee a day. She has no other medical problems and takes no medications. The patient shares that one of her close relatives has epilepsy and is concerned that she had a seizure. Vital signs are within normal limits and physical examination shows no abnormalities. Which of the following is the most likely diagnosis in this patient?

Question

A 20-year-old college student comes to the emergency department accompanied by her roommate after an episode of falling to the ground and "shaking all over."  Her roommate was able to record part of the episode on her phone, which shows the patient lying on the ground, rhythmically shaking all 4 extremities, and tightly closing her eyes.  The roommate is heard asking multiple questions but the patient remains nonresponsive.  The episode resolves within 1 minute, when the patient gets up and asks her roommate to take her to the emergency department.  The patient has been studying for upcoming final exams, has had minimal sleep, and has consumed multiple cups of coffee a day.  She has no other medical problems and takes no medications.  The patient shares that one of her close relatives has epilepsy and is concerned that she had a seizure.  Vital signs are within normal limits and physical examination shows no abnormalities.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient's seizure behavior associated with forceful eye closure and absence of self-injury, incontinence, or postictal confusion is suggestive of psychogenic nonepileptic seizure (PNES). PNES is considered a type of conversion disorder as the clinical findings are inconsistent with seizures or other known neurological conditions. Although no single clinical finding can definitively diagnose PNES versus epileptic seizures, suggestive features include forceful eye closure, side-to-side head or body movements, rapid alerting and reorienting, and memory recall of the event. PNES events typically occur in front of witnesses, and these patients may model their behavior after a friend or relative with epilepsy. Unlike seizures, PNES is not associated with abnormal cortical activity during the episode. Video-electroencephalogram monitoring is considered the gold standard for diagnosis as it is more likely to capture an event and demonstrate lack of associated epileptiform activity. A psychiatric assessment is crucial as many patients with PNES have comorbid psychiatric disorders and/or a history of trauma. (Choice A) Caffeine intoxication can cause heart palpitations, anxiety, and psychomotor agitation. In severe cases, it may precipitate a seizure, cardiac arrhythmia, and/or hallucinations. The features of this patient's seizure behavior are more consistent with PNES. (Choice B) Cataplexy is a feature of narcolepsy and occurs when there is a sudden loss of muscle tone, resulting in brief paralysis. Attacks are usually precipitated by a strong emotion (eg, anger, excitement) and consciousness is maintained. (Choice C) Generalized tonic-clonic seizures are characterized by an abrupt loss of consciousness, followed by stiffening of the muscles throughout the body, and then rhythmic jerking of the extremities. The eyes are usually open during the ictus. Most patients fall asleep immediately after a seizure and will experience postictal confusion on awakening. (Choice D) Panic attacks are sudden, intense episodes of fearfulness or discomfort accompanied by physical symptoms such as palpitations, shortness of breath, sweating, chest pain, and trembling. Symptoms tend to peak within minutes and consciousness is not affected. (Choice E) Paroxysmal dyskinesia is a type of movement disorder in which episodic attacks of involuntary motor dysfunction (eg, dystonia, choreoathetosis) occur. These episodes are usually precipitated by sudden movement, exercise, or stress. Consciousness is preserved. Educational objective: Psychogenic nonepileptic seizure (PNES) is a type of conversion disorder commonly misdiagnosed as a seizure disorder. Features suggestive of PNES include forced eye closure, side-to-side head or body movements, memory recall of the event, and lack of postictal confusion. The gold standard for diagnosis of PNES is video-electroencephalogram of an event demonstrating lack of epileptiform activity. References: Nonepileptic seizures: an updated review. (http://www.ncbi.nlm.nih.gov/pubmed/26996600)

A 20-Year-Old College Student Comes to the Emergency Department Accompanied