What is the best course of management for a 15-year-old female student with a history of psychiatric stressors, including family conflict and discovery of her true parental identity, who presents with recurrent episodes of dizziness, shortness of breath, and involuntary movements, with no prior history of psychiatric illness or persistent anxiety symptoms?

Management of Recurrent Psychogenic Non-Epileptic Episodes in an Adolescent with Significant Psychosocial Stressors

This 15-year-old patient is experiencing conversion disorder (functional neurological symptom disorder) manifesting as psychogenic non-epileptic seizures (PNES), triggered by significant family trauma and ongoing psychosocial stress, and requires a comprehensive psychiatric evaluation with focused medical workup to exclude organic causes, followed by psychotherapy-centered treatment with family involvement.

Initial Diagnostic Approach

Medical Clearance Strategy

Perform selective, targeted medical testing based on clinical presentation rather than routine extensive laboratory workup. 1

• Essential focused evaluation includes:

  • Vital signs assessment (fever, tachycardia would suggest organic etiology) 1
  • Neurological examination to assess for focal deficits, altered mental status, or cognitive impairment 1
  • Targeted laboratory testing only if history or physical examination reveals concerning findings 1

• In this clinically stable patient (alert, cooperative, normal vital signs, preserved awareness during episodes, voluntary control of symptoms), routine extensive laboratory testing is NOT indicated 1

• Key clinical features supporting functional/conversion etiology:

  • Preserved awareness during episodes 1
  • Ability to voluntarily unclench hands despite sensation of forced closure 1
  • Episodes triggered by identifiable stressors (school settings, emotional situations) 1
  • Symptoms resolve with reassurance or distraction 1

Critical Pitfall to Avoid

Do not order extensive neuroimaging (CT/MRI) or EEG unless specific neurological signs are present on examination. 1 Studies demonstrate that in psychiatric patients without focal neurological findings or altered mental status, the yield of neuroimaging is no greater than in the general population, and false positives cause unnecessary distress 1

Psychiatric Diagnostic Assessment

Comprehensive Evaluation Components

Conduct separate interviews with the patient and all available family members to establish accurate timeline and context of symptoms. 1

• Document the following systematically:
  • Detailed sequence of events surrounding each episode (triggers, duration, associated symptoms, resolution pattern) 1
  • Complete family psychiatric history focusing on anxiety disorders, depression, and somatoform disorders in first-degree relatives 1
  • Assessment of family structure, communication patterns, and regulatory functioning 1
  • Quality of relationships between patient and both sets of parents 1
  • Current family conflict patterns and caregiver stress levels 1

Differential Diagnosis Framework

Rule out the following conditions through targeted assessment:

1. Panic disorder with hyperventilation - The episodes of dizziness, shortness of breath ("parang humihinga sa straw"), and carpopedal spasm are highly consistent with hyperventilation syndrome 1

2. Adjustment disorder with anxiety - Temporal relationship between family disclosure and symptom onset suggests reactive etiology 1

3. Underlying mood disorder - Screen for persistent depressed mood, anhedonia, sleep disturbance, and suicidal ideation (patient currently denies these) 1, 2

4. Emerging psychotic disorder - The patient denies hallucinations, delusions, or thought disorder, making this unlikely 3, 4

Assessment of Suicide Risk

Despite absence of current suicidal ideation, this patient has multiple risk factors requiring ongoing monitoring: 1

• Significant family conflict and feeling blamed by caregivers 1
• Complex parental relationships and identity confusion 1
• Adolescent female with psychiatric symptoms 1
• Recent onset of fear and worry about health 1

Establish safety planning and provide closely spaced follow-up appointments rather than relying solely on "no-suicide contracts," which may impair therapeutic alliance in adolescents. 1

Treatment Plan

Primary Intervention: Psychotherapy with Family Involvement

Initiate cognitive-behavioral therapy (CBT) targeting the patient's catastrophic health-related cognitions and anxiety symptoms. 1

• CBT should address:
  • Negative cognitions about health and fear of recurrent episodes 1
  • Breathing retraining techniques for hyperventilation management 1
  • Cognitive restructuring of beliefs about symptoms causing problems for parents 1

Concurrent family therapy is essential and non-negotiable in this case. 1

• Family intervention goals:
  • Educate all caregivers that symptoms are involuntary manifestations of psychological distress, not intentional behavior 1
  • Address the caregiver belief system that may view symptoms as manipulative 1
  • Improve communication patterns between patient and legal parents 1
  • Establish predictable routines and reduce environmental stressors 1
  • Process the complex family dynamics surrounding biological versus legal parentage 1

Pharmacotherapy Considerations

Medication is NOT first-line treatment for conversion disorder/PNES, but may be indicated if comorbid anxiety or depression emerges. 1

If pharmacotherapy becomes necessary for anxiety symptoms:

• SSRIs may be considered, but require careful monitoring in adolescents 2
• Risk of increased suicidal thoughts and behaviors in patients under 18 years (14 additional cases per 1,000 patients treated compared to placebo) 2
• Screen for personal or family history of bipolar disorder before initiating any antidepressant 2
• Monitor closely during initial months of treatment and at dosage changes 2

Psychoeducation and Symptom Management

Provide explicit education to patient and family about the mind-body connection in conversion symptoms: 1

• Explain that physical symptoms are real and involuntary, not "faking" 1
• Describe how psychological stress manifests as physical symptoms through known neurobiological pathways 1
• Normalize the experience and provide reassurance that symptoms can improve with appropriate treatment 1

Teach specific coping strategies for acute episodes:

• Controlled breathing techniques (slow diaphragmatic breathing) to prevent hyperventilation 1
• Grounding techniques to manage dissociative symptoms 1
• Identification of early warning signs and triggers 1

Follow-Up and Monitoring

Schedule frequent, closely-spaced appointments initially (weekly for first month, then biweekly). 1

• Monitor for:
  • Frequency and severity of episodes 1
  • Emergence of depressive symptoms or suicidal ideation 1, 2
  • School attendance and academic functioning 1
  • Quality of family relationships and conflict levels 1
  • Development of new symptoms suggesting alternative diagnosis 1

If patient misses an appointment, contact immediately by phone to assess safety and re-engage in treatment. 1

Coordinate care with school personnel to:

• Provide accommodations during acute episodes without reinforcing sick role 1
• Monitor for triggers in school environment 1
• Ensure patient can access support when needed 1

Prognosis and Long-Term Considerations

Conversion disorder in adolescents generally has favorable prognosis with appropriate psychotherapeutic intervention, particularly when family dynamics are addressed. 1

Poor prognostic indicators to monitor:

• Persistent family conflict and lack of caregiver engagement in treatment 1
• Development of secondary gain from symptoms 1
• Emergence of additional somatic symptoms 1
• Transition to chronic pain or disability patterns 5

The bidirectional relationship between symptoms and function requires emphasis on functional recovery rather than complete symptom elimination. 5 Focus treatment goals on return to full school participation and age-appropriate activities even if occasional mild symptoms persist 5