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bless

Organic or anxiety?

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Hi friends I have a difficult case. Any suggestions are welcome please.

Female with symptoms of anxiety, depression. Getting a feeling of devil possessing her. She could hear screaming noises and felt extremely anxious didnt go out. Gp who gave her haloperidol 1.5 mg bd she was later seen by my consultant - diagnosed severe depression with anxiety and stopped haloperidol.

She started having collapses when she was arguing. She would just collapse and then wake up after some time in a confused state. Collapses has become so frequent that she has this every day sometimes 2or 3 times. some times will sleep afterwards for almost 2.5 hours. It was also noticed that some times during these episodes she would kick her limbs so hard and somebody had to hold her. She had one of these episodes while with psychologist and psychologist said she just went back in in her chair and for 10 minutes she was not arousable. Neurologist did some 48 hr tape, MRI etc and nothing was found.

Psychologist still feels it is psychological but in our team dicussion one of the consultant suggested narcolepsy and cataplexy and I also felt the epilepsy should be ruled out.She is also very much concerned of this episodes but never seen her really down but she doesnt have that indefferent attitude of dissociative disorders. So re referred to neurologist.I am waiting for his reply.she is on sertraline 150mg since the last years episode. Any suggestions friends??????????!!!!!!!!!!!!!

Edited by Gurpal
Patient details removed to preserve confidentiality

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My first suspicion would be epilepsy. EEG would be helpful.

Also would rule out diabetes.

Extreme emotions can cause vasovagal syncope.

http://en.wikipedia.org/wiki/Vasovagal_syncope

A dissociative disorder cannot be rules out even if she does not have an indifferent attitude.

Interesting case. Do keep updating.

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It's Not epilepsy !

The history that you have provided is not consistent with the diagnosis of epilepsy , nor is it consistent with narcolepsy.

it looks like psudo seizures

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what are the secondary gains ? I would seek a cardiologist opinion too.

what are the results of psychological assessment?

I dont think its organic and it would be interesting to see whats the outcome.

cheers

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20 year old

Female

Never been diagnosed to have epilepsy in the past...

No other h/s/o organicity like a FND or SOL on MRI

Family history of depression

Broken family and stressors - need to satisfy both parents...

Possible cluster C Premorbid traits

Now presenting with Depressive and Anxiety symptoms... (worthwhile going into details of anxiety to r/o panic attacks; generalised anxiety; etc...)

At some point in time... she believed she had an organic illness (which may be worth exploring) - possibly linked to why she is getting these episodes now...

Only possible precipitating stressor from the histroy given is watching a horror movie (or the trip to Central park- whichever was more horrible...)

Looking for other precipitating stressors would be a good move

Investigations I would suggest to r/o all causes of anxiety...

Thyroid/adrenals/diabetes

UPT to r/o pregnancy although I dont think she will be pregnant for 1.5 years

Investigate vasomotor function...

r/o arrhythmias...

But Inner ear pathology; posterior column lesions and syncopal attacks usually dont cause LOC of 2.5 hours...

medications...

EEG is a must... I dont think there is enough history to rule out Seizures/ possibly show sorems if it was narcolepsy... may need sleep studies (you did mention video recording; i would think that was with EEG)

Most probably it is functional (ugghhhh)... but we need to rule out stuff...

Thats as much rubbish I can think of...

keep us posted

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had exactly similar case. turned out to be PD with attention seeking and having episodes of screaming when her case was not agreed upon. Said then could see blood on the walls and thought the devil was after her. Was discharged from ward against her wishes! Relationshp with mum was unhealthy and there were similar traits in mum.

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hi friends

thanks for the response. EEG was done long time ago and was normal.I also thought about cardiac conditions but she is seen by the paramedics many times and my understanding is that she has told the ecg was normal.more suggestions welcome and i will keep posted.

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I also wanted to request the GP to do cardiac investigations but felt a bit uncomfortable in making an already anxious lady more anxious with all these investigations but I will ask him more about it soon.

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Be careful in how aggressive you are with such physical investigations! If there is no serious reason then the lesser the better!

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Very interesting presentation. Sounds psychogenic but it is essential to carry out the investigations to exclude an underlying organic cause.

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You can do Prolactin levels to immediately after these episodes and that will tell you whether thats epilepsy or pseudoseizures............ good luck

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as eeg done longtime ago, worthwhile repeating eeg as antidepressant treatment can precipitate seizures.

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[highlight]what are the secondary gains[/highlight] ? I would seek a cardiologist opinion too.

what are the results of psychological assessment?

I dont think its organic and it would be interesting to see whats the outcome.

cheers

2.5 hours rest at work every time you have a funny do?

Making mum and boyfriend scared to argue with you for fear of you collapsing?

Getting to kick people without being blamed for it?

....I'm tempted myself!

You have to rule out organic briefly but it sounds psychogenic to me.

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Does she have any narcoleptic symptoms i.e. is this something like cataplexy?

If not, it sounds like she is in the Scarlett O'Hara section of ICD-10, rather depressingly for the outcome of such dramatic neuro-somatising.

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A prolactin level may not be a bad idea:

http://www.blackwell-synergy.com/doi/pdf/10.1046/j.1528-1157.2001.11901.x?cookieSet=1

But it seems to only go up in certain types of seizures (complex and secondary generalised).

When I first heard your vignette I was thinking Axis II - especially with the relationship with the older 'father figure', difficult childhood, transitory quasi-psychotic phenomena , etc.

I would get as much collateral info as possible and then :

1. Do a CT (but an MRI head if possible).

2. EEG under the situations that provoke 'em (get her bf to fight with her at the EEG place!)

3. If all normal - my question would be Axis 1 or Axis 2 predominant. If Axis 1 - drugs and psychotherapy. If Axis 2 --> complex cases services or even liasion involvement.

F_S

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If she has had carpet burns and face scratching, that sounds as though she is moving during these 'collapses'.

Main DDs for me would be

Dissociative disorder (given psychosocial stresses)

Factitious disorder (as above but more consciously trying to escape)

Epilepsy

Pseudoseizures (probably more factitious than dissociative)

I would have thought a big help would be a prolactin after one of these episodes- if normal, psychology referral...

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I think that after ruling out epilepsy those collapses may be for attention seeking or taking advantage in a relationship

plus the psychotic like experiences

in my opinion she would go with BORDERLINE PERSONALITY DISORDER

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y not cateplexy?

but i think it is more emotionally unstable anyways. also very clear secondary gains here.

bless -can u rememebr back to 2007? wat hapened?

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This is not narcolepsy.

She needs a 24 hr EEG which if normal again does not sadly rule out epilepsy!!

Does she still have the feelings of the devil possessing her??

Any other quasi / psychotic sx??

Any other features of impulsivity??

A trial of an antiepileptic which could aslo act as a mood stabiliser mey help releive her distress.

If this fails, we would at least have more evidence re the neurotic origin of her symptoms

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You can do Prolactin levels to immediately after these episodes and that will tell you whether thats epilepsy or pseudoseizures............ good luck

easier said than done

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A sleep deprived EEG might be helpful. Interesting case!

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she made it obviusly clear that the cause is her intense anxiety which comes to dramatic presentations so that others must take it seriously; I am saying that because of the reassurance seeking behaviours: lights on at night, hugging pillow, overdramatic calls for her dead grandfather

I wonder what it was like for her when she had the responsibility for looking after her depressed father and her brother; maybe now it's time to say, actually I am a very anxious person

is she buying the house with parents or boyfriend?

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It seems that any seizure disorder should be excluded. A video EEG could be helpful in anxiety provoking situations. The diagnosis as per me is Dissosciative Disorder with Borderline personality traits. Not enough info for diagnosing a personality disorder. Thanx.

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It seems that any seizure disorder should be excluded. A video EEG could be helpful in anxiety provoking situations. The diagnosis as per me is Dissosciative Disorder with Borderline personality traits. Not enough info for diagnosing a personality disorder. Thanx.

Guys would this not be breach of confidentiality? just asking

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It seems that any seizure disorder should be excluded. A video EEG could be helpful in anxiety provoking situations. The diagnosis as per me is Dissosciative Disorder with Borderline personality traits. Not enough info for diagnosing a personality disorder. Thanx.

Guys would this not be breach of confidentiality? just asking

No

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