Case report
In this case report, the patient’s medical history, records and images were reviewed. Ethics committee approval was not necessary as the case fell within the standard of medical care. The patient understands that her name and initials will not be published and due efforts will be made to conceal her identity, but anonymity cannot be guaranteed. Informed consent on the clinical information and images were given by the patient.
A 43-year-old married female worker presented with 3 months history of aggravated paroxysmal discomfort and sudden convulsions. The episodes lasted for about 20 s per time, and she stated that she could remember the whole process of the episode each time. The frequency of her attacks increased from 2 to 3 times per day, to every 5–10 min, to the point where she could no longer sit up .
During episodic exacerbations, she had consulted different neurologists in different hospitals who had diagnosed her as having dissociative (conversion) disorder and anxiety disorder. She tried multiple medications including escitalopram, mirtazapine, sertraline, paroxetine, olanzapine, risperidone, aripiprazole, lorazepam, madopar, and so forth, as well as the modified electric convulsive therapy (MECT) twice and repetitive transcranial magnetic stimulation (rTMS) once. Video electroencephalogram (EEG) including 24 hours EEG, the EEG during seizure and brain MRI are normal. She still tried antiepileptic medications like valproate and madopar for several weeks. However, she had poor response and a fluctuating course in the frequency of attacks. Finally, she was referred to psychiatric services for further treatment.
On our initial evaluation, there occurred repetitive convulsions without any premonitory signs that manifested rigidity and twitching of the limbs with eyes closed tight persisting for 20 s. Immediate neurological examination revealed resistant eyelids, no upturned eyeballs and normal light reflection of pupils.
Physiological reflex was normal, while pathological reflex and meningeal irritation were not elicited. There was no muscle atrophy of extremities. Muscle strength was 5/5 in upper and lower extremities, with an increased muscle tone on right side. No other abnormalities were noted on neurological examination. She was not found to be having significant anxiety symptoms based on Hamilton anxiety rating scale (HAMA) (score <6). EEG and MR angiography showed no abnormality. A final diagnosis of dissociative convulsions was made according to the criteria of the International Statistical Classification of Diseases and Related Health Problems 10th Revision. The patient was subsequently administered venlafaxine, sulpiride and clonazepam, assisted with supportive and verbal suggestion psychotherapy. During individual therapy sessions, she had revealed a number of stressors including being adopted, going through the death of her father in early childhood and being brought up by her compelling mother. She had two daughters and a strained relationship with her husband after her marriage. Later in the sessions, she gained insight, which helped her become more compliant and able to receive good care at home.
However, she denied any conscious efforts in these episodes. The frequency of conversion seizures was significantly reduced after treatment, and the patient could walk by holding the handrails and self-care partially. But as ever before, her condition would deteriorate once we mentioned that she was expected to be released from hospital. The patient’s husband gave up the further treatment and discharged her due to her lack of response towards treatment after 37-day stay.