Question of the Week # 353

353)  A 54 year old woman is found by her husband wandering and trying to undress herself two miles away from her home . Her husband tried to question her, however, she did not recognize him, did not respond to his questions and when he tried to restrain her, she became physically aggressive. Upon presentation in the Emergency Department, she appears confused and does not recall the event. There is no history of drug abuse or alcoholism. There is no history of any significant past medical problems. Examination shows normal vitals. There are no focal neurological deficits. She is confused and not oriented to place and person. Which of the following is the most likely diagnosis?

A)  Temporal Lobe Epilepsy

B) Depersonalization Disorder

C) Domestic abuse

D) Dissociative Fugue

E) Manic Episode

9 Responses

  1. D) Dissociative Fugue??

  2. d….

  3. is it B?

  4. A. Epigastric aura is a characteristic feature of temporal lobe epilepsy.

  5. b

  6. Answer . A

    Temporal lobe epilepsy, also known as, complex partial seizures or psychomotor seizures is an organic syndrome that can mimic psychiatric disorders and is an important differential diagnosis that need to be excluded before making diagnosis of Psychiatric Disorders ( Such as Mania, Dissociative states) . It is the most common type of seizure in adult. The most important clue in this question is that the patient is confused after the event and that indicates a “post-ictal” state. The patient has suffered a complex partial seizure at the time when she was wandering and trying to undress herself. The term “Complex” refers to “loss of consciousness and awareness” – the patient has no awareness of surroundings. Complex partial seizure may often be preceded by a “Simple” Partial seizure ( Also, called Aura) . Aura symptoms can range from flashing lights, nausea, out of body experience, spinning , dizziness etc . During the Aura phase ( simple partial phase) , the consciousness and awareness are preserved whereas during the attack of “complex” partial seizure, the patient loses awareness and consciousness. During the attack, patients may become physically aggressive if they are restraining attempts are made. The symptoms of complex partial seizures can vary massively from person to person. It may be associated with automatisms – repetitive behaviors such as lip smacking, walking, undressing, chewing etc. The Attack typically lasts for less than 3 minutes. After the attack, the patient may remain in post ictal state for several hours ( Post ictal symptoms include confusion, drowsiness, amnesia, thirst etc)

    Option B is incorrect. Depersonalization disorder should not be associated with post-event confusion which characterizes post-ictal state.

    Option C is incorrect. Domestic abuse may be associated with Dissociative amnesia. But the patient’s lack of consciousness and awareness along with post ictal state exclude this diagnosis.

    Option D is incorrect . Dissociative fugue is associated with sudden unexpected travel and loss of memory regarding previous identity. However, a confusion pointing towards post-ictal state is an important differentiating feature. Patient with dissociative fugue are awake, oriented and conscious but have forgotten their previous identity and where they came from. Patients with dissociative fugue do not have any symptoms of “aura”. An “Epileptic” or “organic” fugue as seen with Complex Partial Seizures can usually be recognized because the individual may have an aura, motor abnormalities, stereotyped behavior, perceptual alterations, a postictal state, and abnormal findings on serial EEGs. In this question, there is post-ictal state.

    Option E is incorrect. Manic episode is characterized by a persistently elevated mood, lasting at least one week. The patient is conscious and aware of his surroundings. A brief psychotic disorder is characterized by a sudden onset of psychotic symptoms, which may include delusions, hallucinations, disorganized speech or behavior, or catatonic behavior lasting more than a day but never more than a month – they are non-recurring. A recurring event should consider one to diagnose mania rather than brief psychotic disorder. In the patient above, these diagnoses do not fit as none of them should have post-event confusion that defines post-ictal state.

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