Abstract | March 11, 2024
Medical Trauma in a Young Adult with Psychogenic Nonepileptic Seizures: A Case for Retraining and Control Therapy (ReACT)
Learning Objectives
- Understand the basic principles of ReACT therapy and how they can quickly be incorporated into most clinical encounters
- Develop a framework to discuss PNES with patients and integrate basic ReACT principles into practice with patients in any outpatient or inpatient setting
- Understand that PNES can be debilitating without intervention, but that some interventions do not come in the form of a pill, and most providers can equip themselves with simple skills to aid patients with FND
Introduction: Psychogenic nonepileptic seizures (PNES) are the most common type of functional neurological disorder (FND). PNES is associated with chronic disability and welfare dependence. Studies have shown that anti-epileptic drugs do not improve symptoms burden, and cognitive behavioral therapy results in limited reduction of symptoms. Prolonged episodes occur in 78% of patients with PNES and are often misdiagnosed in the ER as status epilepticus, resulting in large doses of benzodiazepines, and iatrogenic respiratory depression leading to ICU admissions. Retraining and control therapy (ReACT) is a newly developed manualized mind-body intervention that has shown reduction in symptoms for pediatric PNES. In this case, it is applied to a young adult with medical trauma from ICU admissions for PNES.
Case Presentation: Patient is a 21-year-old man with a history of focal epilepsy due to multiple cavernous malformations, status-post resection of right mesial-temporal malformations and new onset PNES. PNES was diagnosed after multiple irretractable episodes of seizure-like activity that resulted in NICU admission and intubation. On discharge, the patient exhibited signs of ICU related PTSD, awakening with flashbacks to intubation and having subsequent PNES activity causing patient to re-present to the ER, with further hospital admissions. Patient established care for ReACT on an outpatient basis. He had episodes of PNES that were lasting the entire day consisting of whole-body clenching, moaning, diminished response to environment, and periodic bilateral upper and lower extremity jerking. He had to stop working due to PNES activity. After 1 session of psychoeducation on PNES, 1 session of behavioral plan development, and 1 session of basic cognitive behavioral therapy, the patient had remission of symptoms throughout a month. Patient had spontaneous recovery of his PNES and then got in a motorcycle accident, requiring hospitalization. After this hospitalization he exhibited increased PNES activity. He continued ReACT completing 1 session on extinction burst with four check-in sessions. He then exhibited improvement in PNES activity, even with subsequent hospitalization for pyelonephritis.
Diagnosis: PNES
Management and Follow-up: Patient still has one relapse and prevention module of ReACT to complete. He also has two more check-in sessions if needed.
References and Resources
- Fobian, A. D., & Szaflarski, J. P. (2021). Retraining and Control Therapy (ReACT) is a bottom-up, body-oriented intervention. Seizure, 92, 236-237. https://doi.org/10.1016/j.seizure.2021.09.015
- LaFrance, W. C., Jr., et al. (2014). “Multicenter pilot treatment trial for psychogenic nonepileptic seizures: a randomized clinical trial.” JAMA psychiatry 71(9): 997-1005.
- Goldstein, L. H., et al. (2010). “Cognitive-behavioral therapy for psychogenic nonepileptic seizures: a pilot RCT.” Neurology 74(24): 1986-1994.
- Haritsa, S. V., et al. (2021). “Randomized Trials of Psychotherapeutic Treatment for Psychogenic Seizures: Scoping Review.” Indian J Psychol Med 43(6): 469-472.
- Jungilligens, J., et al. (2021). “Misdiagnosis of prolonged psychogenic non-epileptic seizures as status epilepticus: epidemiology and associated risks.” J Neurol Neurosurg Psychiatry 92(12): 1341-1345.
