non convulsive pseudo seizures

1. Pseudo seizures with Depression
Anusha.Rameshwaram
PharmD V year,
Roll no:170514882007
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2. Patient name: Mr.KNSH
Gender: Male
Age: 25 years
Weight: 105 kgs
Height: 165 cms
DOA:3/9/18
DOD:9/9/18
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3.  Chief Complaints: Abnormal movement on right side of the body
with secondary generalised siezure like activity and also right hip
pain.
 Past Medical History: His complaints were gradually increasing in
frequency,not controlled by any antiepileptic medicines. Last
episode of seizure was on 1st September 2018 and July 15-Aug 20
suffered with seizures daily. Patient had secondary generalised
seizure like activity since 2011 June 10,there is no aura or post
ictal confusion during the episode’s. C/o blurring of vision, right
half weakness , walking imbalance. Mental disturbances since
2011.
SUBJECTIVE
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4. Family History: No family history of epilepsy
ALLERGY: Allergy to Sulpha drug
Past Medication History:
• T.LEVIPIL(Levetiracetam)500mg(8am) and 1g(8pm) PO
• T.TOPIRAMATE 100mg(8am) and 200mg(8pm) PO
• T.EPILIM CHRONO(Sodium valproate) 1g PO BD
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5.  PHYSICAL EXAMINATION:
• Patient conscious and alert
• Temperature : Normal
• PR:80 breaths/min
• BP:130/80 mm of Hg
• No focal neuronal deficit
 DIAGNOSTIC TEST
• Video EEG : No ictal activity
Suggestive of Psychogenic non epileptic seizures.
• MRI: Normal
• PET-Scan : Mild left temporal hypermetabolic focus.
OBJECTIVE
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6. PROVISIONAL DIAGNOSIS:
Secondary generalized seizure like activity
FINAL DIAGNOSIS:
Non epileptic pseudo seizures
Depression
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7. DAY 1(3/9/18)
O/E :Conscious and oriented
PR- 80bpm
BP: 130/70mm of Hg
CVS : S1S2 +
RS : BAE+
Right hip pain
Antiepileptic drugs are given
Intravenously.
Inj.MEDAZOLAM 1mg IV stat
Inj.TAMIN 1gm IV TID
• All AE Drugs are stopped .
• Inj.TAMIN continued
DAY 2(4/9/18)
PR: 90 bpm
BP:130/80 mm of Hg
EEG : No ictal activity
suggestive of Psychogenic
non convulsive seizures.
MRI: Normal 7

8. DAY 3(5/9/18)
Patient conscious ,alert
Vitals stable
No further seizures
Psychiatry opinion was taken
for psychogenic non convulsive
seizures
CST
ADD: Started on Antidepressants
and Antipsychotics
T.LAMITOR-DT 25mg PO BD
T.NEXITO 10mg PO HS
T.OLEANZ 5mg PO HS
DAY4(6/9/18)
Patient conscious and
oriented
vitals stable
No further seizure activity
Complaining Right hip pain
CST
ADD: T.DOLO 650mg PO TID
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9. DAY 5(7/9/18)
Patient conscious ,alert
No further events
DAY 6(8/9/18)
Patient conscious ,alert,afebrile
Vitals stable
CST
CST
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10. DAY 8(9/9/18)
Patient conscious, alert,afebrile,
cooperative.
No further ictus
Patient discharged
Inj.TAMIN stopped
CST
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11. DRUG CHART
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Brand Generic Dose Freq ROA Category Indication
Inj.MIDAZOLAM Midazolam 1mg STAT IV Benzodiazepine Seizures
Inj.TAMIN Paracetamol 1gm TID IV Analgesic Hip pain
T.LAMITOR-DT Lamotrigine
Dispersable
tab
25mg BD PO Anti
convulsant
Pseudo
seizures
&depression
T.NEXITO Escitalopram 10mg HS PO SSRI-anti
depressant
Depression
T.OLEANZ Olanzapine 5mg HS PO Atypical
Antipsychotic
Depression
T.DOLO Paracetamol 650mg TID PO Analgesic Hip pain

12. Goals of the treatment
• Determining the cause the disorder is a significant part of
treatment.
• Discontinuation of AED therapy.
• To control seizure like activity(Pseudo seizures)
• To prevent recurrence of the Pseudo seizures
• An appropriate Psychiatric intervention to treat mental
disturbances(depression)
• To improve quality of life.
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13. ASSESSMENT
• Mr.KNSH,25 YOM, presented with complaints of seizures
for last 7 years.
• Inj.MIDAZOLAM(Benzodiazepine) 1mg STAT IV was
given to treat Emergency treatment/management of
prolonged seizures. Benzodiazepines increase the activity of
GABA, thereby relaxing skeletal muscles.
• Inj.TAMIN (Paracetamol) 1gm,IV TID was given to treat
right hip pain. It works by blocking the release of certain
chemical messengers that cause pain.
• Neurologist opinion was taken , and based on subjective and
objective evidence, he was diagnosed with Psychogenic non
epileptic seizure.
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14. • All anti epileptic medicines were stopped.
• Psychiatrist opinion was taken and Antipsychotics and Anti
depressant medicines were started.
• T.LAMITOR-DT(lamotrigine) 25mg BD PO an
anticonvulsant which was used to control Pseudo seizures
and also used in the depression.
• There is a strong evidence of efficacy of this anticonvulsant
as therapy in psychogenic disorders.
• It works to maintain mental balance and controls seizures by
decreasing the abnormal and excessive activity of the nerve
cells in the brain.
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15. • The relative safety and better acceptability of SSRIs has
made 1st line drugs in depression.
• T.NEXITO(Escitalopram) 10mg HS PO, SSRI was given to
treat depression, It helps in optimizing the serotonin levels in
the body.
• In a depressed patient, a SSRI may be combined with
relatively lower dose of antipsychotic agent.
• T.OLEANZ(Olanzapine)5mg PO HS , Atypical anti-
psychotic was given to treat depression. It works by affecting
the levels of chemical messengers (dopamine and serotonin)
to improve mood, thoughts and behavior.
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16. • No further seizure activity was observed in the patient.
• Patient was discharged in stable condition.
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17. PLAN
Disease monitoring:
• Monitor for any further seizure like activity
• Monitor for any mental disturbances
Drug Monitoring:
• Escitalopram: Dose-dependent increase in QT interval may
be associated with escitalopram.
• Olanzapine : Long term use may cause weight gain and
hyperglycemia.
• Monitor for clinical worsening, suicidality and unusual
change in behavior, especially, during the initial few months
of therapy or at times of dose changes
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18. Patient counselling:
• Non-epileptic seizures are also commonly referred to as
Pseudo-seizures.
• Nonepileptic seizures are caused by something other than
epilepsy — typically by psychological conditions (Eg:
Depression)
• People with Psychogenic Non Epileptic Seizures typically
carry a diagnosis of epilepsy for roughly 7 years, so an
understanding of the new diagnosis is crucial for their
treatment, which requires patient’s active participation.
• With proper treatment, the seizures eventually disappear in
60-70%
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19. Drug related:
• T.ESCITALOPRAM 10mg to be taken at bed time for
depression.
• T.OLEANZ 5mg to be taken at bed time for depression.
• T.LAMOTRIGINE 25mg to be taken twice daily for
depression
Life style modifications:
• To maintain healthy body weight.
• To walk daily at least for 30 mins.
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