Working Diagnosis:
Psychogenic non-epileptic seizure

Treatment:
Over several weeks, the episodes decreased in frequency and ultimately resolved without further intervention.

Outcome:
Following a neurology consult, she was cleared to resume swimming with supervision. She was to refrain from driving for 6 months from the last episode per Maine state law but had otherwise returned to her daily activities without incident.

Author's Comments:
Psychogenic non-epileptic seizures (PNES) are episodes that appear consistent with a seizure but have no abnormal brain electrical impulses. They are thought to be a manifestation of psychological stress and are more common in patients with prior psychological disorders. In this case, further discussion with the patient's mother revealed stressors including parental divorce and no contact with her father. With the normal evaluation and resolution of symptoms without intervention, PNES was felt to be the most likely diagnosis. When symptoms do not spontaneously resolve, as they did in this case, treatment focus should be on managing the underlying psychological or psychiatric diagnosis.

Editor's Comments:
PNES may also occur after a traumatic event. In athletes with seizure-like activity, it is important to develop and follow an algorithm for evaluation since it is impossible for everyone with seizure-like activities to obtain a video EEG. An algorithm that starts with a collaborative and comprehensive evaluation with neurology, including consideration for a video EEG. After diagnosis, an inter-disciplinary approach involving mental health, neurology, and primary care is taken and both pharmacological and non-pharmacological treatment modalities are used.

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