An unusual presentation of adversive seizures as? Dissociative convulsions,in a 10year old boy with gtcs.-a case report

Abstract

Abstract

A 10year old boy, referred from pediatric department with 3months history of deviation of the neck and both eyes to right side with starring look, followed by dribbling of urine, transient and self-subsiding, which increases in frequency past 1month (once a week, past 3month and 30-40episodes/day, last 1month).These brief lasting episodes occurs mostly in    morning hours, most of the episode without a fall (except  2episodes).such episodes occur even during sleep with  dribbling of urine. The boy claims of being unaware of this  episode.The suspicion of a dissociative component was    entertained when the child revealed that he is able to predict the episode and suddenly disappears when mother pats on his back. Most of the episodes happen before leaving to school and mother started neglecting these episodes. Mother often reinforces the behavior by checking pants following each episode. Our team and pediatric team were able to observe episodes on suggestion. No history of tongue bite, frothing, loss of consciousness, fever. The above clinical presentation is complicated with history of movements of bilateral upper limb and lower limb. Abduction movement of shoulder and both hips with flexion movement of both elbow and knee joint, lasting for 1minute,uprolling of eyeballs, frothing, urinary    incontinence, unresponsiveness loss of consciousness for 5minutes,child reports of tiredness following the episode, was on dual anti-epileptic, defaulted past 1year.History of alcohol dependence in father and resultant significant marital discord in parents.The child was admitted for diagnostic clarification. The frequency of episodes drastically reduced during first week of IP period (10episodes/day with dribbling of urine).The child also had 2-3episodes during sleep which was confirmed by video EEG, the semiology depicted adversive seizure and anti-epileptic was changed as per the neurologist. Considering the reduction in number of epiodes, occurrence of episodes on suggestion and the above history of presenting  illness a probability of dissociative convulsion along with  adversive seizures is considered which needs management with caution in follow up. Mother was psycho-educated to tease between adversive seizure and a probable co-morbid dissociative convulsion  from  GTCS and was discharged. We present this child with an intention and caution for the primary therapist,how atypical an adversive seizure may manifest in a child with history of seizure disorder. We would also like to emphasize the higher incidence of a co-morbid dissociative convulsion in a child with true seizure and the significance of differentiating these two, which entirely differ in management strategies.