A man in his 40s with repeated seizures

The patient's first seizure occurred in connection with a high fever during holiday travel. The seizure consisted of loss of consciousness and atypical convulsions. He was assessed in hospital, including by a neurologist, but no signs of organic brain pathology were found. Increased holiday alcohol consumption combined with high fever were postulated as possible triggering factors. During the next six years he had two similar episodes in connection with a respiratory infection and fever.

Eight years after the first seizure, he began suffering recurrent seizures which started with involuntary movements, mostly of the extremities, during full consciousness and accompanied by hyperventilation. These movements were followed by loss of consciousness without urinary or faecal incontinence and with amnesia concerning the seizure period. The convulsions could last from a few minutes to 40 minutes, and could also occur in series continuing for several hours. On some days he might suffer no seizures, on other days several. Overall, he averaged 6 – 30 seizures per month. The seizures were provoked by job-related stress, insomnia and situations with many people present and noise. After the episodes he was usually sleepy and fatigued, with back- and knee-pain that could last for several days.

After a further three years he experienced increasing difficulty in finding words for objects. He also found that on «bad days», prior to new attacks, both speech and movements were slower.

During these years he was admitted repeatedly to the Neurology Department for assessment, and underwent a lumbar puncture, EEG and MRI of his head. There were no findings that could explain his condition. The EEG was interpreted as mildly pathological with slightly high slow activity over the left front temporal region, but without definite epileptic activity. The conclusion was psychogenic, non-epileptic seizures. He received no medical treatment apart from escitalopram and diazepam, which had no observable effect.

On three occasions he was assessed at specialised epilepsy centres. 24-hour, 26-channel long-term EEG monitoring was conducted during which the patient experienced three of his characteristic seizures. The monitoring revealed short bursts of rhythmic 5 – 6 Hz theta interictal activity, partly spiked temporally with a left-sided predominance, which created uncertainty as to whether it could be a matter of a pathological condition or a rare physiological variant. However, it was concluded that the seizures were psychogenic, and both diazepam and escitalopram were discontinued.

A further two neurological assessments later yielded the same result. On one occasion, 45 mg intramuscular diazepam was administered during a prolonged seizure, without effect.

The conclusion of a psychiatric assessment was that the patient had «dependency and conflict-avoidance tendencies», but no grounds were found for further assessment/treatment. He was also assessed and treated by a psychologist in private practice, but the traditional screening instruments used yielded no evidence of a mental disorder. However, the Minnesota Multiphasic Personality Inventory (MMPI) (8) revealed conflict-avoidance features, psychosomatic reaction tendencies, unconscious suppression, intensified control, aggression inhibition and limited self-insight. It was assumed that the patient had a relatively limited coping and reaction repertoire, with a tendency towards dissociation and a psychosomatic seizure reaction in stressful situations. Therapy focused primarily on insight into the personality background to the seizures, triggering factors, and how seizures could be prevented. The patient cooperated well, but the therapy resulted in no lasting improvement in the frequency or severity of the seizures.

During six weeks of observation and assessment in a psychiatric department, several incidents involving loss of consciousness and convulsions were observed weekly. The patient was discharged with the diagnosis dissociative convulsions (F 44.5). He tried pregabalin for a few weeks, but without effect.

The problems in question resulted in increasingly frequent sick leave and finally in disability pensioning, 14 years after the first seizure.

After the patient had reported over time, apparently for no reason, a growing tendency to depressivity and irritability, especially prior to seizures, his primary doctor referred him again to a regional psychiatric centre with a request for «psychological assistance in tackling situations when his seizures occur». The patient described himself to the psychiatrist as a very energetic and emotionally unstable person who responded with irritability and excessive emotional reactions to small incidents. He mentioned problems in keeping calm, particularly when he felt engaged, and that in periods before he was put on disability pension he was able to work more than 12 – 14 hours a day, with little need for sleep (3 – 4 hours per day) and little sense of tiredness. Evidence of bipolar disorder type II was found, and the patient agreed to lamotrigin treatment. The drug was titrated up in the normal way to a daily dose of 200 mg.

Some weeks after the start of treatment, a considerable, stable improvement took place in the patient's state of health and quality of life. His seizures grew fewer and shorter, the patient felt his mood was more stable, he had better control of his feelings and he stopped feeling unsteady. A few months later his daily dose was increased to 300 mg. Some weeks after that, he averaged one fifteen minute seizure every second week. He was still less irritable and his mood was more stable. During one period he experienced a number of conflict-filled situations and on some days he had a number of seizures, but he still remained generally more stable and calm. He described his quality of life as substantially improved. After a consultation with the neurologist, the dose was gradually increased to 600 mg daily, and serum lamotrigin was measured as 29 mmol/ml (10 – 60 mmol/l). After this the seizures occurred an average of 1 – 2 times per month and lasted for 15 – 20 minutes. About 2.5 years after starting on lamotrigin, the patient has seizures at intervals of 3 – 4 weeks. He is satisfied with his treatment, feels stable and reports a good quality of life.