A Case of Complex Post‐Traumatic Stress Disorder Manifesting With Psychogenic Non‐Epileptic Seizures

ABSTRACT

In cases where complex post‐traumatic stress disorder (CPTSD) co‐occurs with psychogenic non‐epileptic seizures (PNES), it is essential to emphasize that severe interpersonal trauma is strongly associated with PNES. Failure to recognize this association may result in misdiagnosis, inappropriate treatment (including polypharmacy), and potential iatrogenic harm.

1. Introduction

Complex post‐traumatic stress disorder (CPTSD) is a severe mental disorder that develops in response to prolonged and repeated traumatic life events such as sexual abuse, torture, and prolonged domestic violence. The condition was first described in 1992 by American Psychiatrist Judith Herman to describe the effect of prolonged trauma, including disturbance in affect regulation, self‐perception, and relationships. The fourth version of the diagnostic and statistical manual for mental disorders (DSM‐IV) included the concept of Disorders of Extreme Stress‐Not otherwise specified’ (DESNOS), which included Symptoms of affect dysregulation, dissociation, somatization, altered self‐perception, altered relationships, and changed sustaining beliefs, which was adapted from Judith Herman, but still the diagnosis was not incorporated in DSM‐V (2013) [1]. The International Classification of Diseases (ICD‐11) in 2022 introduced CPTSD as a separate diagnosis from classical PTSD [2]. Complex PTSD can be diagnosed across the lifespan, including children and adolescents, using the same criteria [3].

According to ICD‐11, diagnosing Complex PTSD requires three PTSD core elements, which are re‐experiencing, avoidance, and persistent perception of threat, and three complex PTSD specific symptoms of problems in affect regulation, persistent negative beliefs about oneself, and difficulties in interpersonal relationships. Approximately 15%–48% of individuals with PTSD have been found to meet diagnostic criteria of Complex PTSD, which corresponds to 1%–8% population prevalence. Among patients with Complex PTSD, 35%–49% meet criteria for PNES [4].

Psychogenic non‐epileptic seizure is a recurrent paroxysmal episode that mimics epileptic seizure without the electrophysiological changes seen in EEG. In the DSM‐V, PNES belongs to the category of “conversion disorders” under the heading of “functional neurological symptom disorders.” Studies have shown that PNES patients and Complex PTSD share a close psychopathological profile, as they share many clinical features, particularly a history of severe repeated trauma dating from childhood, with different clinical presentations. The hypothesis went far by saying PNES may be the tip of the Complex PTSD iceberg [5].

We present a case of a 19‐year‐old female with a history of periodic spells of staring towards one direction, which was preceded by symptoms suggestive of psychogenic non‐epileptic seizure, with a history of sexual assault, being bullied, and experiencing emotional and physical trauma. The symptoms did not improve with antipsychotics and antiseizure medication but showed improvement with an SSRI (sertraline) and psychotherapeutic interventions.

2. Case Report

The patient was brought by her mother to the psychiatry clinic on 2nd April 2025 following a one‐week history of periodic staring characterized by unresponsiveness lasting 10 min, occurring 4–6 times per day exclusively during daytime. The episode was not preceded by an aura, eye blinking, or any movements. There were also no incontinence, lateralisation signs, or postictal disturbances. She did not have any history of concurrent manic, depressive, or anxiety symptoms.

These recent symptoms were preceded by a one‐year history of multiple episodes characterized by falling, screaming, side‐to‐side head turning, tonic–clonic movements of extremities, and pelvis thrusting. The episode lasted for 30 min, occurring five to six times during a day and at night. Some episodes were characterized by flailing of the upper and lower limbs, eye closure, and being aware of self and surroundings. The events were precipitated by anger, but there was no history of incontinence or lateralisation signs. There was no history of paralysis, tremors, abnormal gait, sensory deficits, speech disturbances, visual or auditory impairments. The patient previously attended a regional referral hospital for psychiatric consultation, where she was prescribed multiple medications, including Haloperidol, Carbamazepine, Fluoxetine, Risperidone, Lamotrigine, Sodium Valproate, Fluphenazine, Trifluoperazine, Clonazepam, Diazepam, Quetiapine, and Levetiracetam. However, the history lacks specific details regarding the dosage, frequency, duration of use, and the reason for shifting between these medications.

Her past psychiatric history revealed that, three years before this psychiatry clinic visit, the patient experienced auditory hallucinations in which she heard her sister crying and asking for help; however, she has no history of depersonalization or derealisation. These symptoms lasted for approximately three weeks and resolved following spiritual intervention at church, after which she made a full functional recovery.

Her personal history revealed significant trauma including sexual assault by the age of four years and being bullied by her peers due to big breast at the age of 14 years, she endured emotional and physical punishment from her father who accused her of feigning her symptoms, she was also repeatedly exposed to parental conflicts and intimate encounters which exacerbated her symptoms of episodic staring and tonic clonic movements. Psychosocial assessment revealed a history of being an introvert with few friends, distrust of men, poor peer relationships, low self‐esteem, and self‐harm behavior.

Following this personal history, she exhibited avoidance behavior, including distancing from her father and male peers, and an inability to reveal sexual assault events. She also had dissociative reaction (loss of awareness of surroundings), negative beliefs about herself, negative emotions (anger), negative self‐perception, and sleep disturbance.

3. Methods

General and neurological examinations were normal. Mental status examination (MSE) revealed normal findings across most parameters. However, the patient exhibited a sad mood and a constricted affect. By using the International Trauma Questionnaire (ITQ) the patient met the criteria for Complex PTSD, with clinically significant scores (≥ 2) across all required PTSD and Disorder of self‐organization symptoms, supported by severe functional impairment in relationships, self‐concept, and affective dysregulation. Following ITQ assessment and ICD‐11 criteria, which include three classical symptoms of PTSD co‐occurring with symptoms of disturbance of self‐organization, a diagnosis of Complex Posttraumatic Stress Disorder was established. Based on history and semiological characteristics, PNES was also diagnosed.

Investigations included an electroencephalogram (EEG) and a brain magnetic resonance imaging (MRI) scan, both of which revealed normal findings. Other investigations, including an electrocardiogram, echocardiogram, renal function test, liver function test, thyroid function test, serum electrolytes, complete blood count, random blood glucose, VDRL, and an HIV test, were also performed and were unremarkable.

The patient was diagnosed with Complex Posttraumatic Stress Disorder with Psychogenic Non‐Epileptic Seizures. Initial management included psychoeducation for both the patient and her parents regarding the diagnosis, the impact of prolonged and repeated trauma, and the treatment plan. A phased, trauma‐informed psychotherapeutic approach followed. The first phase emphasized stabilization, including developing emotional regulation skills, managing symptoms, and strengthening the therapeutic alliance. After stabilization, trauma‐focused exposure therapy was initiated to facilitate the processing of traumatic memories, and Cognitive behavioral therapy (CBT) was integrated throughout treatment to address maladaptive cognitions, avoidance behaviors, and coping strategies, while interpersonal therapy was employed to improve interpersonal functioning. At the time of writing this case report, the patient attended fourteen sessions of psychotherapy. Sertraline 50 mg once daily was given two weeks before the start of psychotherapy due to the severity of symptoms such as negative beliefs about herself, negative emotions (anger and sadness), and negative self‐perception, to enable the patient to engage effectively in psychotherapy.

4. Conclusion and Results

At the time of writing this case report, the patient had shown significant improvement following the assessment with the ITQ, the patient scored zero on both symptoms of classical PTSD and disturbance in self‐organization, with no PNES attacks. Sertraline was stopped after using it for fourteen months following the improvement of symptoms. She has successfully enrolled as a first‐year student at the university and was attending an outpatient psychiatry and psychological clinic.

5. Discussion

Given that PNES is highly prevalent in Complex PTSD, in our case, limited awareness of this condition, limited trauma education among clinicians, overlapping of symptoms, and the diagnosis not being incorporated in diagnostic tools such as DSM‐5‐TR have hindered a holistic approach in the management of this patient [6]. The presence of classical symptoms of PTSD in this patient, co‐occurring with symptoms of disturbance of self‐organization, aligns well with a diagnosis of complex PTSD. Also, both PNES and Complex PTSD can occur following a response to prolonged and repeated traumatic life events [7].

In clinical settings, sometimes it can be difficult to differentiate between epileptic seizures and PNES. Still, the combination of a history, semiological characteristics, and video EEG findings can help to diagnose PNES [8]. Especially in this case, none stereotypical pattern of the movements she had, including pelvic thrusting, arms flailing, screaming throughout the episode, being aware during the episode, and being precipitated by anger (though this also can occur in true epileptic seizure), duration of 30 min, eye closure during ictal period, and normal EEG findings with positive history of polytrauma gives much weight to PNES than actual epileptic seizure.

For a person to function normally, various constructs and neural circuits must be in sync. The clinical presentation of this patient aligns with other studies that have shown the disturbance of cognitive‐behavioral, psychoanalytic, and neurobiological models following polytrauma leads to disconnection of constructs and neural circuits, in which a top‐down approach involving the prefrontal cortex and the amygdala becomes disturbed. Amygdala hyperactivity and hypo‐functionality of the prefrontal cortex have been found in patients with Complex PTSD. For example, paroxysmal movements can be perceived as involuntary by an individual with PNES due to a dysfunction of the construct of agency, which is driven by abnormalities of a temporal–parietal‐based circuit [9].

Earlier presentation of psychotic‐like symptoms to this patient might alternatively reflect dissociative phenomena. This is typically seen in patients with a long history of multiple trauma, which can also explain the PNES symptoms that she had [10]. In this case, the fact that the patient's auditory phenomena resolved without the use of antipsychotics argues more for dissociative phenomena rather than primary psychotic disorder.

There is limited evidence that recommends antidepressant treatment in patients with complex PTSD unless they have comorbid depression or anxiety. Our patient has shown improvement after being kept on 50 mg of sertraline in combination with psychotherapeutic interventions, including trauma‐focused exposure, cognitive behavioral therapy, and interpersonal therapy. Currently, psychotherapeutic interventions have been recommended as the primary treatment of complex PTSD [11, 12]. Trauma‐focused psychotherapies such as exposure therapy, eye movement desensitization and reprocessing, and cognitive behavioral therapy have shown significant effectiveness [13].

The use of semi‐structured interviews in obtaining the diagnosis of CPTSD and the involvement of a neurologist in excluding Epilepsy stand as a limitation in this case report.

Complex PTSD, even though it was not incorporated in DSM‐V, has been included in other diagnostic tools like ICD‐11. Further studies can help in including this diagnosis in the subsequent DSM versions, as the symptoms tend to differ from those narrated in classical PTSD. A high index of suspicion should be kept in mind when seeing a patient with a history of polytrauma presenting with disturbance of self‐organization.

Author Contributions

Mgabo Mabusi: conceptualization, writing – original draft, writing – review and editing. Sarah A. Richard: conceptualization, writing – original draft, writing – review and editing. Julius Jaji: conceptualization. Paul Lawala: supervision. Azan Nyundo: supervision, writing – review and editing. Innocent Mwombeki: conceptualization, supervision, writing – review and editing.

Funding

The authors have nothing to report.

Consent

Written informed consent was obtained from the patient for publication of this case report. A copy of the written consent is available for review by the Editor‐in‐Chief of this journal.

Conflicts of Interest

The authors declare no conflicts of interest.

Data Availability Statement

The data supporting this study's findings are available from the corresponding author upon reasonable request.