1. Ms Shivi to me: “Dr. I am a burden on my parents. I am good for nothing. I have wasted my parents’ hard-earned money. All my friends are better than me. I wish I could just die so that my parents would be relieved.”
#MedTwitter #NeuroTwitter #psychtwitter
#MedTwitter #NeuroTwitter #psychtwitter
2. 18-year old Shivi was brought to OPD with repeated convulsions for 3 days. She was taken to physician in her village, who started her on anti-epileptic drugs (AEDs). Despite being on two AEDs at maximum doses, her convulsions continued. Physician referred her to a neurologist.
3. As per parents, Shivi was having 25-30 episodes of convulsions per day. During the attack, she would breathe heavily, eyes would close, back would bend in an arch, and arms and legs would become extended. She would fall down and won’t be able to speak.
4. Parents were anxious (as expected) & wanted the best treatment for their daughter. I witnessed a seizure attack in OPD. It matched the description as mentioned above. Based on observations, I considered an alternate diagnosis (and not epilepsy); ordered for a video EEG test.
5. Video EEG confirmed our suspicion- it was non-epileptic seizures.
During the recording, Shivi had a few more attacks, but EEG did not show abnormal epileptiform discharges during those attacks.
But our job was only half done, as we still needed to find the root cause.
During the recording, Shivi had a few more attacks, but EEG did not show abnormal epileptiform discharges during those attacks.
But our job was only half done, as we still needed to find the root cause.
6. I interviewed Shivi’s parents. They were farmers & with their meager income, wanted the best education for their 4 children.
Shivi was the eldest & they expected her to become a doctor. However, she scored poorly in NEET, and they couldn’t afford to enroll her in any college.
Shivi was the eldest & they expected her to become a doctor. However, she scored poorly in NEET, and they couldn’t afford to enroll her in any college.
7. They denied that Shivi was stressed; however, I wanted to interview Shivi without her parents being present. This is when she opened up and mentioned what I wrote at the beginning of this thread.
Now, the diagnosis was confirmed: Psychogenic non-epileptic seizures (PNES).
Now, the diagnosis was confirmed: Psychogenic non-epileptic seizures (PNES).
8. I explained the diagnosis to Shivi’s parents and requested them to get a Psychiatry opinion. This was not well received by her father- “Dr. you are saying my daughter is mad. She is the best-behaved of our children. You have wasted our time & money, and we are leaving”.
9. The situation was challenging. I had to delicately handle it.
I discussed the case with psychiatrist and explained to parents that it is a brain disease (brain and mind are same). So, we need treatment inputs from two specialists of brain diseases- neurologist & psychiatrist.
I discussed the case with psychiatrist and explained to parents that it is a brain disease (brain and mind are same). So, we need treatment inputs from two specialists of brain diseases- neurologist & psychiatrist.
10. Shivi’s parents accepted my proposal and agreed to follow up with both psychiatrist as well as neurologist.
Shivi was started on antidepressant and antipsychotic medications. Counseling sessions were also started.
She was asked to come for regular follow up visits.
Shivi was started on antidepressant and antipsychotic medications. Counseling sessions were also started.
She was asked to come for regular follow up visits.
11. Shivi showed excellent response to treatment, and became symptom-free in 10 weeks.
Shivi continued to follow up until six months, & was then lost to follow up.
She hadn’t consulted the psychiatrist too; however, psychiatrist conveyed that she was well when last seen by him.
Shivi continued to follow up until six months, & was then lost to follow up.
She hadn’t consulted the psychiatrist too; however, psychiatrist conveyed that she was well when last seen by him.
12. I had almost forgotten about Shivi (whom I had last seen in 2017), when she came for review last week. “Dr. I am not a patient today. I too became a doctor and today’s visit to thank both the doctors who saved me and gave a new direction (& purpose) to my life”.
13. Shivi informed that she wants to pursue a post graduation in psychiatry, and be of help to many more people like her. She hoped that stigma associated with mental illnesses would be eliminated and all patients could receive the psychiatric care without any guilt or shame.
14. The life had come a full circle but the roles were about to get reversed- she would be the healer and not a patient. I wished her the best.
15. Take home message
*In a patient presenting with repeated seizures despite being on adequate doses of AEDs, suspect a diagnosis of PNES.
*Detailed history is needed to determine the underlying cause.
*Psychiatric treatment (& team approach) leads to successful outcome in PNES.
*In a patient presenting with repeated seizures despite being on adequate doses of AEDs, suspect a diagnosis of PNES.
*Detailed history is needed to determine the underlying cause.
*Psychiatric treatment (& team approach) leads to successful outcome in PNES.
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