1. Introduction

Psychogenic Non-Epileptic seizures (PNES) are a form of the functional neurological disorder (FND). FND has been described to date back to Hippocrates in 700 B.C. The terminology has been evolved over the centuries. FND includes the following hysteria, psychogenic complaints, dissociative states, neurologically unexplained symptoms, somatoform disorder and conversion disorder [1]. Conversion disorder is the term which has been used previously for PNES. As per the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (American Psychiatric Association, 2013, “conversion disorder” is changed to “Functional neurological symptom disorder” [2]. The International Classification of Diseases-10 (ICD-10) classified it under the Dissociative disorder [3]. The dissociative disorder is defined as a partial or complete loss of the normal integration between memories of the past, awareness of the identity and immediate sensation, and control of bodily movements. Any physical illness does not explain the appearance of the symptoms and evidence for underlying psychological factor is required to make a diagnosis of Dissociative disorder [2, 3]. In PNES, the symptoms resemble with the seizures but are not related to any dysfunction of the brain or physical illness. The event in the PNES is a psychological or emotional response to stress or psychological trauma and not due to the consequences of abnormal electric discharges of the brain [4-6]. The clinical picture of PNES can vary from motor movements of limbs/body like posturing in the classic “arc en circle” position, asynchronous motor movements, eye fluttering or forced eye closure, and pelvic thrusting. Vocalization may also occur, including yelling, screaming, or crying. It may also include difficulty breathing or hyperventilation, dizziness, headaches, and tachycardia [7]. The prevalence rate varies from 1.4-33 per 100,000 population; the rate almost reached up to 5-50% people with seizures disorder [8-12]. It is believed that PNES tends to occur in young to middle-aged female, with a family history of psychological and psychiatric history, but is known that it can occur at any age from 4-90 years of age [13]. In the last decade, with the increasing ageing population, the issue of epilepsy in the elderly has received great attention [14]. However, a little data is available at the onset of PNES in the elderly, although there have case reports mentioning such an entity [15]. A few retrospective data are also available to describe the PNES in the elderly, however the reliability is doubtful [16].  

2. Case Report

A 61-year-old widowed female, mother to 2 children, educated up to 8^th standards, belongs to middle socioeconomic status hails from an urban background. She was brought to the psychiatric clinic with the complaints of abnormal limbs movements, loss of consciousness and shortness of breath. Her initial complaint started around four months back of the very first visits to the psychiatric clinic. As stated by patient and relatives that she had an altercation with her brother, issues related to the property dispute. She was preoccupied with the same, that her brother would cheat her and take away all her property which belongs to her. As stated, the cost of the property was around one crore rupees. After a few days of the same, her sister-in-law expired and went to attend the funeral of her’s sister-in-law. There again, she had an altercation with her brother. Following which she became unconscious, with closed eyes, clenching of teeth, abnormal jerky movements of limbs (upper as well as lower limbs) not associated with frothing from the mouth, urine and faecal incontinence, uprolling of eyeballs lasted for about 30 minutes, not responding to external stimuli. She became responsive after 30 minutes, oriented to time, place and person. There was no post-ictal confusion. Following she was taken to a Government speciality hospital, after monitoring of vitals, she was referred to a neurologist for the episode of loss of consciousness. She visited a neurologist, started on Tab. Valproate up to 1 gm/day. Blood investigation like complete blood count, Liver function test, Renal function test, Thyroid function test and EEG were done, all were within normal limit. EEG was also normal. However, She remained preoccupied about the same that her brother would take away all the property. She would think that if she would not get anything, how she would be able to take care of herself, what would happen to her children. Whenever, she would be alone, would keep on thinking about the same. In addition to the above episodes, also have shortness of breath along with Gabhart. Despite good compliance, there was no decrease in the frequency of the episodes of loss of consciousness. After about two months of the above episode, while talking with her relatives about the property, again had the same episode of loss of consciousness with similar semiology, lasted for about 1 hrs. Immediately, she was taken to a Neurologist. Her vitals including blood pressure, pulse rate, respiratory rate were within normal range. She was afebrile to touch. The routine blood examination, urine examination and EEG were assessed that were within normal limits. Neuroimaging (MRI Brain with epilepsy protocol) was normal, no pathologic factor was evident. Repeated EEGs were normal along with Video EEG was normal. For the same, referred to the Psychiatry Clinic. She did not express any sadness, anxiety and kept on talking about the “dispute of property”. The patient diagnosed with Dissociative Convulsion Disorder based on ICD-10 diagnostic criteria, a treatment of 10 mg/day Escitalopram and Clonazepam 0.25 mg sos was initiated. Tab. Valproate was stopped. Relaxation exercise was taught to the patient. Problem-solving technique started and taught how to deal with “stress”. She had only one episode of loss of consciousness in the next one month. She became fit after one month, but would keep on talking about her problem during the session of psychotherapy.  

3. Discussion

Psychogenic non-epileptic seizures are paroxysmal behaviour change episodes that resemble real seizures, which are not accompanied by EEG variations as in our index case. Detailed clinical history, physical and neurological examinations and related laboratory tests resulted in the exclusion of all organic factors that could cause loss of consciousness. The MRI Brain with epilepsy protocol as taken in our case as a supplement to clinical examination demonstrated that the episodes of loss of consciousness were not epileptic. The patient was diagnosed with Dissociative convulsion Disorder. It is a well-known fact that dissociation is a way for people to handle the acute pain that the trauma has inflicted upon their psyches by offering a kind of emotional release and blunting that separates their mind from the pain that their body endured, and experience themselves as separate from their bodies. The secondary gains play an important role in the persistence of the disease [17]. As in our index case, the stress was related to the occurrence of the episode of loss of consciousness. Previous studies also suggested the same that dissociation is associated with antecedents stress. Most of the studies showed that about two-third patients had stress as the precipitant factor. Family conflict was the most common one [18-20]. It must be kept in mind that dissociative disorder is used to observe in young population between the ages of 15 and 35, could be possible in the elderly population at any time. In our patient, the motor activity was predominant, which is similar to previous studies of the elderly patients [15, 16]. In our patient, the clinical and EEG ictal features and lack of change when AEDs were discontinued strongly favour the diagnosis of psychogenic non-epileptic seizures [21].  

A psychotherapeutic approach is required to increase the awareness for the patient’s feelings, thoughts and to avail an environment for the expression of these emotions without being criticised and judged was initiated. Our patient improved significantly in a period of 2 months with the psychotherapeutic approach, was on follow up regularly after that.  

4. Conclusion

This case is a rare occurrence of the dissociative disorder in this age group, as with age certain changes occurs in the psychic apparatus, the ego starts to have functioning poorly as compared to young age. Hence, the situation makes it difficult to develop an appropriate solution in the presence of stress and use of effective strategies. However, the dissociative disorder is a rare entity in this age group. The correct diagnosis of PNES requires careful, detailed clinical history, taking with appropriate and adequate witness accounts. In clinical practice, inadequate attention to psychosocial stress factors is common due to limited clinician awareness, understanding, or time to spend counselling the patient. If PNES are suspected, then recording an event with time-locked VEEG and confirming that this event was typical of the patient and witness is the most reliable investigation. Witnesses may demonstrate, for example, tremor rather than clonic movements. History taking may reveal significant psychological stresses and a history of psychiatric disorder, although it is important to remember that patients with epilepsy and other types of non-epileptic events may be anxious, depressed and may have been subject to significant traumatic life events. The early diagnosis and treatment of PNES may positively influence the patient’s outcome and also save the healthcare cost. It is important to recognise the PNES in elderly peoples as early as possible.  

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