Diagnosis: Psychogenic Non-Epileptic Seizures (PNES)
This teenage girl is most likely experiencing psychogenic non-epileptic seizures (PNES), also known as pseudoseizures, based on the prolonged duration (1-2 hours), limp body presentation, visual hallucinations, and emotional aftermath—all features that strongly distinguish PNES from true epileptic seizures.
Key Diagnostic Features Supporting PNES
The clinical presentation contains multiple red flags for PNES rather than epileptic seizures:
Prolonged duration: Episodes lasting 1-2 hours are far too long for epileptic seizures, which typically last 74-90 seconds 1. Loss of consciousness exceeding 5 minutes strongly suggests PNES rather than true seizures 1.
Limp body (flaccid collapse): This presentation is more consistent with syncope or PNES rather than the tonic-clonic stiffening characteristic of epileptic seizures 1.
Visual hallucinations with round clear shapes: While visual hallucinations can occur in epilepsy, the specific description and prolonged nature suggest a non-epileptic etiology 2.
Emotional aftermath: The prominent emotional response following episodes is characteristic of PNES, where patients often experience significant psychological distress 3.
Immediate Diagnostic Workup
The single most critical diagnostic step is video-EEG monitoring to capture a typical episode, which will show normal cortical background rhythms during the event despite apparent unresponsiveness 3, 4.
Essential evaluations include:
Video-EEG recording: Must document at least one typical episode showing persistence of normal EEG activity during apparent seizure-like behavior 3, 4.
Comprehensive psychiatric evaluation: Screen specifically for mood disorders (depression, bipolar disorder present in 32% of cases), separation anxiety with school refusal (24% of cases), and history of sexual abuse (32% of cases, especially with comorbid mood disorders) 3.
Medical exclusion: Rule out organic causes including infectious diseases, intoxications, medication side effects, and neurological conditions—nonpsychiatric causes account for 43% of hallucinations in children presenting to emergency departments 2. Consider NMDA receptor antibody testing if atypical features present 5.
Psychosocial stressor assessment: Evaluate for severe family stressors including parental divorce, discord, death of family members (present in 44% of cases), and history of abuse 3.
Treatment Algorithm
Once video-EEG confirms PNES, immediately discontinue any antiepileptic medications and initiate psychiatric treatment—this approach results in freedom from pseudoseizures in 72% of patients, with 53% achieving remission within one month of diagnosis 4.
Step 1: Diagnostic Disclosure
- Present video-EEG findings to patient and family, clearly explaining episodes are emotional in origin and medically not worrisome 4.
- Emphasize this is a firm diagnosis requiring psychiatric rather than neurological treatment 4.
Step 2: Psychiatric Treatment Based on Comorbidities
For mood disorders (depression, bipolar disorder): Initiate appropriate antidepressants or mood stabilizers with close monitoring for severe psychosocial stressors, particularly sexual abuse history 3.
For separation anxiety with school refusal: Address moderate psychosocial stressors with cognitive-behavioral therapy and gradual school reintegration 3.
For conversion disorder without major psychiatric comorbidity: Psychotherapy focusing on stress management and coping mechanisms 3.
Step 3: Ongoing Management
- Maintain psychiatric follow-up for 9-55 months (mean 30 months) to ensure sustained remission 3.
- Monitor for recurrence, which is less likely with prompt diagnosis and treatment initiation 4.
Critical Pitfalls to Avoid
Do not continue antiepileptic medications after PNES diagnosis is confirmed—this reinforces the illness behavior and delays psychiatric treatment 4.
Do not delay psychiatric evaluation waiting for additional neurological testing once video-EEG is diagnostic 3, 4.
Do not miss sexual abuse history: Specifically inquire about sexual abuse, present in 64% of patients with comorbid mood disorders 3.
Do not overlook brief reactive psychosis or schizophreniform disorder: Present in 6% of cases and requires different treatment approach 3.
Prognosis
With prompt video-EEG diagnosis followed by immediate psychiatric intervention, 78% of pediatric patients achieve complete freedom from episodes, with the majority experiencing their last pseudoseizure within one month of diagnosis 4. The combination of clear diagnostic communication and appropriate psychiatric treatment targeting underlying mood disorders, anxiety, or trauma yields excellent outcomes 3, 4.