A 20 year old female of normal intelligence is presented. She has been accepted to university to read a health science. She presented with seizures at age 7 years. Her initial symptoms were episodic flashing coloured lights. Subsequently accompanied by contortion of the face, a small convulsive event with flexion of the right arm, clenching of the fist, groaning noises, head turning to the left and witnessed intermittent unresponsiveness. Recovery was immediate but sometimes train of thought was lost. Her initial treatment with levetiracetam was successful but seizures recurred; topirimate, lamotrigine and perampanel were added in turn. EEGs have shown asymmetric anterior predominant spike and wave activity with an emphasized on the left, and bursts of fast activity on left. An MRI scan showed bilateral sub-ependymal nodular heterotopia, most prominently surrounding the left lateral ventricle More recently however the patient indicated that her attack comprised of slumping, associated with falling, head dropping and finger twitching. These episodes occurred 3-9 times per day and were associated with facial injury. Because of the change of the semiology of the attack and the dramatic escalation of the frequency of the attacks, videotelemetry was requested to evaluate the events further. Videotelemetry recorded an habitually typical event arising from the awake state which comprised of slumping, dropping the mobile phone and sitting motionlessly before showing asynchronous shaking of the limbs. The EEG showed a rhythmic alpha frequency discharge over the left hemisphere.
DISCUSSION: Slumping has been described as a predominant feature associated with non-epileptic attack disorder. More recently Hoeritzauer et al 2017 “revisited” a term originally coined by Stevens and Matthews (1973) of “Cryptogenic drop attacks”. Such attacks were associated with a high frequency of comorbid functional somatic and neurological disorders, and speculatively proposed that they “…may be best understood as phenomena on the spectrum of dissociative attacks”. It is common for patients to bring a video clip of an attack on a smart phone. It has been suggested that video alone may be sufficient to make an accurate diagnosis of a seizure disorder versus non-epileptic attack disorder (Erba et al 2016).
CONCLUSION: This case study indicates that slumping is not always a feature of dissociative disorder and video without EEG is not always diagnostically reliable.