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Towards a quantitative assessment of psychogenic nonepileptic seizures

2015 with new-onset epilepsy and ongoing generalized tonic–clonic seizures despite a trial of lamotrigine at an adequate dose. His seizures were not exercise induced and he had not sustained any seizure-related injuries. Routine outpatient electroencephalography (EEG) was unremarkable. An upcoming medical assessment for a training academy provoked anxiety that his rugby career could be halted simply by disclosing a diagnosis of epilepsy. We noted that his epilepsy might be assumed to be attributable to prior rugby-related concussions and that speculation regarding future head injuries and seizure exacerbation might result in him being deemed unfit to play professionally. Other concerns were the implications of poorly controlled seizures and medication-related sedation on sporting performance. We undertook prolonged inpatient video-EEG monitoring to characterize his epilepsy syndrome. Specifically, we sought to determine whether his epilepsy was focal in nature and whether the previous concussive head injuries were causative. Standard provocation measures with antiepileptic drug (AED) withdrawal and sleep deprivation did not produce any clinical seizures over 4 days, but interictal EEG was diagnostic of a genetic generalized epilepsy (GGE) syndrome, showing very infrequent and brief bursts (14 bursts, each lasting <1 s) of generalized, bifrontally predominant polyspike and slow-wave activity at 3 Hz. These findings demonstrated with reasonable certainty that the patient’s epilepsy was unrelated to previous rugby injuries, and prompted a switch to sodium valproate monotherapy in addition to a renewed focus on lifestyle measures and avoiding seizure triggers. A magnetic resonance imaging (MRI) brain study with susceptibility-weighted sequences was negative for traumatic cortical microhemorrhages, providing him with considerable reassurance. The patient was subsequently seizure-free at 3-month follow-up and continues to play rugby at a very high level. He understands that he is unlikely to have seizures during rugby games and feels much more confident in facing future medical assessments in his career. We suggest that careful diagnostic testing, which might vary from case to case, can mitigate the impact of negative attitudes toward epilepsy and allow elite athletes to continue performing in sports.