This patient should have continuous video electroencephalographic (EEG) monitoring for further evaluation of the seizures, which have become increasingly frequent and have not responded to two antiepileptic drugs (AEDs). Video EEG monitoring, performed in an epilepsy-monitoring unit, enables correlation of patient behavior with seizure activity on an electroencephalogram. This can lead to better characterization of seizure activity, such as the identification of specific localizing features, and allow assessment of potential non–seizure-related behaviors suggestive of nonepileptic seizures. This patient has several risk factors for psychogenic nonepileptic events. The long duration of the episodes is more typical of nonepileptic than epileptic seizures, as is the fact that his eyes remain closed during the event. The presence of incontinence does not exclude a nonepileptic episode. Although his previous closed head injury puts him at risk for epileptic seizures, it does not exclude the possibility of nonepileptic events. In fact, combat veterans, particularly those with posttraumatic stress disorder (PTSD), are at high risk for nonepileptic seizures. This diagnosis can be overlooked if a history of head trauma is present. Because epileptic and nonepileptic seizures can coexist in the same patient, a thorough description and characterization of the seizures are essential and best achieved by admission to an epilepsy monitoring unit.

Ambulatory EEG monitoring allows more prolonged evaluation of brain activity outside a clinical setting and may be helpful in identifying seizures or interictal epileptiform activity that may not have been seen on a routine interictal EEG study. However, inpatient video EEG monitoring allows analysis of both clinical and EEG characteristics of seizures to assist in diagnosis and management. The latter study is required for a diagnosis of nonepileptic seizures and presurgical evaluations in patients who have not responded to two or more AEDs. The inpatient setting also allows for withdrawal of AEDs in a monitored environment.

A definitive diagnosis is necessary before adding more AEDs, such as carbamazepine or levetiracetam. Furthermore, levetiracetam should be avoided in this patient with PTSD because it can exacerbate anxiety and irritability.