NU678 Unit 7 Longitudinal Case, Functional Seizures Example

Two Years of Levetiracetam for Seizures That Were Not Epileptic: A Longitudinal Case of Functional Seizures in a 24-Year-Old Veterinary Technician, Followed Over Four Visits and Six Months

[Student Name]

Purdue University Global

NU678: PMHNP Diagnosis and Management Across the Lifespan Clinical III

Unit 7 Longitudinal Patient Case

[Instructor Name]

[Date]

The patient is composite; doses, scores, dates and frequencies are bracketed.

Visit 1: The Referral and a New Diagnosis

What changed. Ms. [D.], [24], works as a veterinary technician. For two years she had been treated for epilepsy with levetiracetam, increased to [1,500] mg twice daily, with no reduction in her events: episodes of shaking with her eyes closed, lasting [five to fifteen] minutes, about [four] times a week. She had stopped driving and was on medical leave. During a [five]-day admission to an epilepsy monitoring unit, [three] typical events were recorded on video-EEG without epileptic activity before, during or after. Neurology diagnosed psychogenic nonepileptic seizures, which I will call functional seizures, and referred her to us.

What was decided and why. The diagnosis met the highest level of certainty in the International League Against Epilepsy's staged approach, which ranks diagnostic confidence from possible to documented and reserves documented for cases where a typical event is recorded on video-EEG without epileptiform activity, in a patient with a consistent history (LaFrance et al., 2013). My first task was therefore not to question the diagnosis but to help her understand and accept it. I explained that her seizures are real and not faked, that they arise from a problem in how the brain handles certain states rather than from electrical discharges, and that they can improve with the right treatment. I screened for depression and anxiety (PHQ-9 [14], GAD-7 [12]) and asked about past trauma; she said, "Nothing worth mentioning." Neurology planned to taper the levetiracetam, and I agreed to follow her mood during the taper. I referred her for cognitive behavioral therapy informed psychotherapy.

What the decision assumed. That she would accept the diagnosis enough to engage with treatment. She said she was relieved that it was not epilepsy but frightened that people would think she was "making it up."

Visit 2, Week 4: The Taper and a Second Revision

What changed. Neurology had reduced her levetiracetam by half. She reported feeling less irritable, which she had assumed was her personality. Her events were unchanged at about [four] a week. In the third therapy session, she had disclosed a sexual assault at [19], which she had never told a clinician. With her agreement, the therapist sent a brief summary.

What was decided and why. I assessed trauma-related symptoms. She described nightmares, avoiding the neighborhood where the assault occurred, startling at sudden noises and feeling detached from her body, and her PCL-5 score was [49]. I revised the diagnosis to include posttraumatic stress disorder alongside functional seizures. This mattered for treatment: the therapy would need to address trauma, and the events themselves might be understood partly as dissociative responses to reminders.

The diagnosis changed twice in four weeks, first from epilepsy to functional seizures and then to functional seizures with PTSD, and each change was made by evidence that had been there all along but had not been asked for.

What the decision assumed. That the trauma was relevant to the seizures, which is common but not universal. I told her that not everyone with functional seizures has a trauma history, so that she would not feel the diagnosis depended on it.

Visit 3, Week 12: A Question of Medication

What changed. Levetiracetam had been stopped. Her events had fallen to about [one] a week after [eight] therapy sessions. Her PHQ-9 was [13] and her PCL-5 [44]; she was still having nightmares and still not driving or working.

What was decided and why. I considered adding sertraline. The evidence directly on functional seizures is limited. In a small multicenter pilot trial, CBT-informed psychotherapy, alone or with sertraline, reduced seizures, while sertraline alone did not significantly reduce them compared with usual care (LaFrance et al., 2014). I therefore did not start sertraline to treat the seizures. I did start it at [25] mg, increasing to [50] mg after a week, to treat her PTSD and depressive symptoms, which were independent reasons to use it, and told her clearly what I expected it to help and what I did not.

What the decision assumed. That her therapy would continue as the main treatment for the seizures. It also assumed that seizure frequency was not the only measure of progress, which became important at the next visit.

Visit 4, Month 6: A Setback and an Emergency Plan

What changed. After a stretch of [five] weeks without events, she had a cluster of [six] seizures over two days following a court date related to the assault. During one, at a shopping center, bystanders called an ambulance. In the emergency department she was given intravenous lorazepam, and intubation was discussed before a neurologist on call recognized her from the monitoring unit. She was discharged the same day, shaken.

What was decided and why. The setback was not a failure of treatment but a predictable response to a major trauma reminder. Her PTSD symptoms had otherwise improved, with a PCL-5 of [33]. The immediate risk was not the seizures themselves but the treatment they might provoke in an emergency department unaware of her diagnosis. With her agreement, I wrote a one-page emergency plan: her diagnosis with the monitoring unit's confirmation, a request to avoid benzodiazepines and airway interventions unless clinically required for another reason, and a phone number for the neurology team. She carries it and it was added to her record. We also discussed expectations. In the largest randomized trial of CBT for dissociative seizures, adding CBT to standardized medical care did not significantly reduce seizure frequency at twelve months compared with medical care alone, though several secondary outcomes, including how bothersome the seizures were and the longest seizure-free period, favored the CBT group (Goldstein et al., 2020). I shared this plainly. Her goal, I suggested, might be a life that the seizures no longer control, even if they sometimes occur.

Synthesis: Reading the Four Decisions Together

Each decision was shaped by the one before. Explaining the diagnosis at the first visit made it possible for her to disclose the assault in therapy, because she no longer feared being dismissed. The PTSD diagnosis at the second visit changed the therapy's focus and gave a reason for sertraline at the third, independent of the seizures. And the honest expectation set at the third visit, that medication would help mood but not the seizures, made the setback at the fourth easier to understand without despair.

The thread running through all four visits was her wish to return to work with animals and to drive again. At the first visit that seemed far away. By the sixth month she had returned to work [three] half-days a week with her employer's agreement, and was discussing with her neurologist when driving might be possible under her state's rules. Framing the goals in terms of her work, rather than seizure counts alone, kept her engaged through a setback that could otherwise have ended treatment.

What the Case Teaches

Functional seizures are often treated as epilepsy for years before video-EEG shows otherwise. When the diagnosis arrives, how it is explained shapes everything that follows. A longitudinal view shows that diagnoses in psychiatry are revised as new evidence emerges, that medication should be matched to the conditions it can treat, and that the patient's own goals are a more useful measure of progress than any single count.

References

Goldstein, L. H., Robinson, E. J., Mellers, J. D. C., Stone, J., Carson, A., Reuber, M., Medford, N., McCrone, P., Murray, J., Richardson, M. P., Pilecka, I., Eastwood, C., Moore, M., Mosweu, I., Perdue, I., Landau, S., & Chalder, T. (2020). Cognitive behavioural therapy for adults with dissociative seizures (CODES): A pragmatic, multicentre, randomised controlled trial. The Lancet Psychiatry, 7(6), 491-505. https://doi.org/10.1016/S2215-0366(20)30128-0

LaFrance, W. C., Jr., Baird, G. L., Barry, J. J., Blum, A. S., Frank Webb, A., Keitner, G. I., Machan, J. T., Miller, I., & Szaflarski, J. P. (2014). Multicenter pilot treatment trial for psychogenic nonepileptic seizures: A randomized clinical trial. JAMA Psychiatry, 71(9), 997-1005. https://doi.org/10.1001/jamapsychiatry.2014.817

LaFrance, W. C., Jr., Baker, G. A., Duncan, R., Goldstein, L. H., & Reuber, M. (2013). Minimum requirements for the diagnosis of psychogenic nonepileptic seizures: A staged approach. Epilepsia, 54(11), 2005-2018. https://doi.org/10.1111/epi.12356