Management of Self-Injurious Behavior, Aggression, and Psychogenic Non-Epileptic Seizures in Patients With Tuberous Sclerosis: A Case Report With a Review of Literature

Tuberous sclerosis complex (TSC) is a neurocutaneous disorder that affects multiple systems. TSC encompasses neurobehavioral abnormalities that are considered less sensitive and specific to the disease. Autism spectrum disorder, attention deficit disorder, anxiety, mood disorders, and self-injurious behavior (SIB) are neurobehavioral manifestations associated with tuberous sclerosis. Among them, SIB is poorly described and studied. We present a case report and a brief review of the literature, which offers us insight into the pathological mechanism that explains associated SIB in TSC patients and provides a possible multidisciplinary approach to handle this complicated association. The case details a 21-year-old female with tuberous sclerosis who went to the emergency department and then transfer to the psychiatric floor due to aggressive behavior and SIB. The patient had a history of infantile spasm in childhood and generalized tonic-clonic seizures (GTCS); the last episode was four years ago at the age of 17. During the hospital admission, the patient developed an apparent tonic-clonic seizure. Nevertheless, the electroencephalogram (EEG) shows no epileptiform pattern and because of the clinical presentation, it was concluded she had psychogenic nonepileptic seizures (PNES). The patient's CT scan showed a stable appearance of multiple calcified subependymal nodules and left frontal hypodensity. Mini-mental examination (MMSE) revealed mild cognitive impairment. Patients with TSC/SIB have higher frequencies of mental retardation, TSC2 mutations, history of infantile spasms, spike focus in the left frontal lobe. Also, TSC/SIB patients have a higher frequency of tubers in quadrants other than the left posterior neuroanatomical region in left occipital, parietal, and posterior temporal lobes. Our patient had four out of five of the risks factor for developing TSC/SIB. Almost all patients with tuberous sclerosis are expected to develop seizures. Nevertheless, our patient was seizure-free for two years and managed prophylactically with antiepileptic medication. PNES can also occur in patients with tuberous sclerosis. It is essential to be attentive to differentiate PNES from actual seizures due to their history of the high frequency of seizures in TSC. Given the multiple systems involved in the symptomatology of TSC, including the SIB and neurological concerns, multidisciplinary treatment strategies must be implemented. Treatment of TSC with SIB should include antiepileptic drugs covering seizures and managing the SIB's mood component. A neuroleptic could be added for patients who are difficult to manage.