Improvement of Superimposed Pseudo Seizures in a Patient With Anxiety Disorder

Introduction: Pseudoseizures or psychogenic non epileptic seizures (PNES) are associated to mental health disorders and stress.2 PNES can often present superimposed with seizure disorder and abnormal EEG, making it harder to be recognized and treated. We present a complex case of seizure disorder status post CVA with superimposed PNES in the context of Bipolar disorder, Somatization and Anxiety disorder. Case Description: LA is a 39 yo female with PMHx of CVA with left sided residual weakness, thyroid disease, seizure disorder who presents with active jerking movements in left lower extremity that started during her neurology outpatient visit. Patient was AAO. Neurological examination was only significant for residual severe spasticity of left upper extremity and active shaking and spasm of both legs, first on left leg thereafter switching to right leg and back to left leg for over an hour, including during EEG. Emergency EEG was performed with patient having active shaking and tremor-like symptoms, being normal. Symptoms resolved after patient learned that EEG did not show active ictal activity. Upon psychiatric evaluation, patient endorsed anxiety, insomnia, mood swings, and somatic symptoms: pain, headaches. MSE was negative for active SI/HI, paranoia or psychosis. Testing for HAM-A was 27 and Somatic symptom scale-8 was 18. Patient was started on Lamotrigine, Sertraline and Clonazepam, with improvement of her symptoms. Discussion: This case highlights the importance to be vigilant for pseudoseizures1 since misdiagnosis can often lead to inappropriate treatment, increase in readmission rates and comorbidities2.