Case Study: Recurrent Convulsive Falls Upon Standing in a 36-Year-Old Female

Case at a Glance

A 36-year-old female with a history of bipolar disorder presented with new-onset, violent, convulsive-like episodes and subsequent falls occurring moments after standing. The episodes resulted in recurrent injuries, prompting an evaluation for orthostatic hypotension, medication side effects, and other neurologic causes.

Patient's Story

The patient is a 36-year-old female who reported a distressing new pattern of episodes. She stated that approximately 50% of the time when she rises from a sedentary position, she feels normal for about five to ten steps. This is followed by an abrupt onset of what she describes as 'dizziness' and violent, full-body spasms. She reported that the involuntary movements are so severe she loses postural control. In an attempt to prevent a more serious fall, she tries to drop to her knees but often falls uncontrollably, frequently hitting her face or head. A recent fall was severe enough to cause significant head and facial pain. The patient has been unable to identify any correlation with food, sleep, or medication timing despite her efforts. Her medical history is notable for bipolar disorder, managed with lamotrigine, gabapentin, and lurasidone.

Initial Assessment

The patient presented with a history of well-managed bipolar disorder on a stable psychotropic regimen. A significant change in her history was a decline in physical activity over the past two years following an unspecified injury, leading to a sedentary lifestyle and noted loss of muscle mass, although her body weight remained low. She specifically denied classic presyncopal symptoms like lightheadedness or tunnel vision, emphasizing the 'convulsive' nature of the episodes. She mentioned that recent laboratory work and imaging studies, performed for an unrelated issue, were unremarkable. Her blood pressure, which she notes typically runs high, has only been measured in a seated position during routine clinical visits.

The Diagnostic Journey

The initial diagnostic consideration, prompted by the clear postural trigger, was orthostatic hypotension. Although the patient's description of 'convulsions' seemed atypical, it was recognized that severe, transient cerebral hypoperfusion can manifest as convulsive syncope. The immediate recommendation was for a formal assessment of orthostatic vital signs—measuring blood pressure and heart rate in supine, sitting, and standing positions—to identify a significant drop upon standing. The patient’s medication list was flagged as a major potential contributor, as all three agents (lamotrigine, gabapentin, lurasidone) can be associated with dizziness and orthostatic hypotension. Her significant physical deconditioning was also considered a primary exacerbating factor, as the loss of lower extremity muscle tone impairs the skeletal muscle pump responsible for returning blood to the heart upon standing.

Final Diagnosis

While a definitive diagnosis requires clinical confirmation, the leading working diagnosis is Orthostatic Hypotension with associated Convulsive Syncope, likely multifactorial in etiology. The primary contributors are suspected to be medication side effects (polypharmacy with agents known to affect blood pressure) and severe physical deconditioning. The convulsive movements are believed to be myoclonic jerks secondary to transient global cerebral ischemia during the hypotensive episode, rather than a primary seizure disorder.

Treatment Plan

The proposed management strategy was initiated pending a formal workup with her primary care physician (PCP):

1. Immediate Safety Measures: Education on rising slowly and in stages (e.g., sitting at the edge of the bed for a minute before standing) to allow for hemodynamic compensation.
2. Non-Pharmacological Interventions: Strong recommendation to increase fluid and sodium intake (if not contraindicated) and consider wearing compression stockings to improve venous return.
3. Physical Rehabilitation: Referral to physical therapy was recommended to begin a gradual reconditioning program focusing on strengthening lower body and core muscles.
4. Medication Review: The patient was advised to consult her PCP and prescribing psychiatrist for a comprehensive medication review. The goal would be to assess whether any of her medications could be adjusted, reduced, or substituted to minimize hypotensive effects without compromising her psychiatric stability.

Outcome and Follow-up

The patient was strongly advised to schedule an urgent appointment with her PCP for a formal evaluation, including orthostatic vital signs, to confirm the diagnosis. Follow-up would be critical to assess the efficacy of conservative measures. Should symptoms persist, further investigation with a tilt-table test to formally diagnose orthostatic intolerance and possibly an EEG to definitively rule out an underlying seizure disorder would be warranted. Any adjustments to her psychiatric medications would require close collaboration between her PCP and psychiatrist to ensure her mood remains stable.