Addressing evaluation challenges and incorporating psychotherapeutic interventions in the diagnosis of functional seizures: A case report

Abstract

Functional seizures (FSs) are a subset of functional neurological disorders frequently misdiagnosed due to their clinical overlap with neurological conditions. Unlike epileptic seizures, they occur without abnormal neuronal discharges and manifest through diverse motor, sensory, and cognitive symptoms. This case report presents the diagnostic trajectory of a patient initially misdiagnosed with stroke-related motor symptoms and later epilepsy, subsequently reevaluated at Ramos Mejía Hospital in Buenos Aires. A comprehensive multidisciplinary assessment involving a differential diagnosis process was conducted to confirm the diagnosis of FSs by ruling out epilepsy, autoimmune encephalitis, and concomitant psychosis. The implementation of targeted psychoeducation, symptom monitoring, and interventions based on the integrative cognitive model resulted in significant clinical improvement, including reduced seizure frequency and enhanced functional mobility. Furthermore, psychotherapeutic strategies facilitated patient acceptance of the diagnosis and adherence to treatment. This case underscores the diagnostic challenges associated with FSs and highlights the importance of a multidisciplinary, individualized approach to optimize symptom management and patient outcomes.

Keywords

Functional neurological disorders / Functional seizures / Misdiagnosis / Psychotherapeutic intervention / Diagnostic challenges

Acknowledgments

None.

Funding

This research was supported by Universidad de Buenos Aires, Argentina (grant no.:UBACyT20020170100274BA).

Conflict of interest

The authors declare that they have no competing interests.

Author contributions

Conceptualization: María Marta Areco Pico, Cristina Tenreyro, Luciana D’Alessio

Investigation: Maria Marta Areco Pico, Cristina Tenreyro, Carla Diamela Portinari, Natalia Piris Mannucci, Damian Eduardo Consalvo, Luciana D’Alessio

Methodology: Maria Marta Areco Pico, Cristina Tenreyro, Mercedes Sarudiansky, Luciana D’Alessio, Guido Pablo Korman

Writing-original draft: Maria Marta Areco Pico, Cristina Tenreyro, Carla Diamela Portinari

Writing-review & editing: Maria Marta Areco Pico, Cristina Tenreyro, Mercedes Sarudiansky, Carla Diamela Portinari, Luciana D’Alessio

Ethics approval and consent to participate

This study was approved by the Ethics Committee of Hospital Ramos Mejía. The patient provided written informed consent to participate in the study.

Consent for publication

Patient consented on the publication of their data.

Availability of data

Data are available from the corresponding author upon reasonable request.

References

[1] Espay AJ, Aybek S, Carson A, et al. Current concepts in diagnosis and treatment of functional neurological disorders. JAMA Neurol. 2018; 75(9):1132-1141. doi: 10.1001/jamaneurol.2018.1264

[2] Hallett M, Aybek S, Dworetzky BA, McWhirter L, Staab JP, Stone J. Functional neurological disorder: New subtypes and shared mechanisms. Lancet Neurol. 2022; 21(6):537-550. doi: 10.1016/S1474-4422(21)00422-1

[3] Reuber M, Rawlings GH. Nonepileptic seizures - subjective phenomena. Handb Clin Neurol. 2016;139:283-296. doi: 10.1016/B978-0-12-801772-2.00025-4

[4] Nicholson TR, Carson A, Edwards MJ, et al. Outcome measures for functional neurological disorder: A review of the theoretical complexities. J Neuropsychiatry Clin Neurosci. 2020; 32(1):33-42. doi: 10.1176/appi.neuropsych.19060128

[5] Stone J, Carson A. Functional Neurologic Symptoms: Assessment and Management. Neurol Clin. 2011; 29(1):1-18. doi: 10.1016/j.ncl.2010.10.011

[6] Carson A, Hallett M, Stone J. Assessment of patients with functional neurologic disorders. Handb Clin Neurol. 2016;139:169-188. doi: 10.1016/B978-0-12-801772-2.00015-1

[7] Duncan R, Razvi S, Mulhern S. Newly presenting psychogenic nonepileptic seizures: Incidence, population characteristics, and early outcome from a prospective audit of a first seizure clinic. Epilepsy Behav. 2011; 20(2):308-311. doi: 10.1016/j.yebeh.2010.10.022

[8] Villagrán A, Eldøen G, Duncan R, Aaberg KM, Hofoss D, Lossius MI. Incidence and prevalence of psychogenic nonepileptic seizures in a Norwegian county: A 10-year population-based study. Epilepsia. 2021; 62(7):1528-1535. doi: 10.1111/epi.16949

[9] Brown RJ, Reuber M. Towards an integrative theory of psychogenic non-epileptic seizures (PNES). Clin Psychol Rev. 2016; 47:55-70. doi: 10.1016/j.cpr.2016.06.003

[10] Wesselingh R, Butzkueven H, Buzzard K, Tarlinton D, O’Brien TJ, Monif M. Seizures in autoimmune encephalitis: Kindling the fire. Epilepsia. 2020; 61(6):1033-1044. doi: 10.1111/epi.16515

[11] Clancy MJ, Clarke MC, Connor DJ, Cannon M, Cotter DR. The prevalence of psychosis in epilepsy; A systematic review and meta-analysis. BMC Psychiatry. 2014; 14(1):75. doi: 10.1186/1471-244X-14-75

[12] Gargalas S, Weeks R, Khan-Bourne N, et al. Incidence and outcome of functional stroke mimics admitted to a hyperacute stroke unit. J Neurol Neurosurg Psychiatry. 2017; 88(1):2-6. doi: 10.1136/jnnp-2015-311114

[13] Gibson LM, Whiteley W. The differential diagnosis of suspected stroke: A systematic review. J R Coll Physicians Edinb. 2013; 43(2):114-118. doi: 10.4997/JRCPE.2013.205

[14] Hankey GJ, Blacker DJ. Is it a stroke? BMJ. 2015;350:h56. doi: 10.1136/bmj.h56

[15] Chen DK, Majmudar S, Ram A, et al. Change in illness perception is associated with short-term seizure burden outcome following video-EEG confirmation of psychogenic nonepileptic seizures. Epilepsy Behav. 2018; 83:186-191. doi: 10.1016/j.yebeh.2018.03.007

[16] Goldstein LH, Chalder T, Carson AJ, et al.Cognitive behavioural therapy vs. Standardised medical care for adults with dissociative non-epileptic seizures (codes): Progress in a randomised controlled trial. Epilepsia. 2016;57:28‐29. doi: 10.1111/epi.13609

[17] Howlett S, Reuber M. An augmented model of brief psychodynamic interpersonal therapy for patients with nonepileptic seizures. Psychotherapy (Chic). 2009; 46(1):125-138. doi: 10.1037/a0015138

[18] LaFrance WC, Miller IW, Ryan CE, et al. Cognitive behavioral therapy for psychogenic nonepileptic seizures. Epilepsy Behav. 2009; 14(4):591-596. doi: 10.1016/j.yebeh.2009.02.016

[19] Zaroff CM, Myers L, Barr WB, Luciano D, Devinsky O. Group psychoeducation as treatment for psychological nonepileptic seizures. Epilepsy Behav. 2004; 5(4):587-592. doi: 10.1016/j.yebeh.2004.03.005

[20] Reuber M. Dissociative (non-epileptic) seizures: Tackling common challenges after the diagnosis. Pract Neurol. 2019; 19(4):332-341. doi: 10.1136/practneurol-2018-002177

Funding

Universidad de Buenos Aires, Argentina(grant no.: UBACyT20020170100274BA)