Dissociative or psychogenic seizures

Wesley T Kerr PhD (

Dr. Kerr of David Geffen School of Medicine at UCLA has no relevant finanacial relationships to disclose.

)
John M Stern MD (

Dr. Stern, Director of the Epilepsy Clinical Program at the University of California in Los Angeles, received honorariums from Greenwish, Sunovion, and UCB as an advisor and from Greenwich, Eisai, LivaNova, and UCB as a lecturer.

)
Originally released July 26, 1994; last updated February 23, 2020; expires February 23, 2023

This article includes discussion of dissociative or psychogenic seizures, psychogenic seizures, dissociative seizures, hysteroepilepsy, nonepileptic seizures, pseudoseizures, psychogenic seizures, psychogenic status, psychogenic nonepileptic attack, psychogenic nonepileptic attack disorder, psychogenic nonepileptic events, dissociative seizures, conversion disorder with seizures or attacks, and functional neurologic disorder with seizures or attacks. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Otherwise known as psychogenic nonepileptic seizures, dissociative seizures often challenge even experienced epilepsy experts in their diagnosis because of their behavioral overlap with epileptic seizures, their potential comorbidity with epilepsy, and the limited quality of patient/witness descriptions of seizures. Once diagnosed, they pose the additional challenges of understanding their cause and providing effective treatment. In this review, the fundamental clinical aspects of dissociative seizures are surveyed, including issues of differential diagnosis, prognosis, and management.

Key points

 

• Dissociative seizures mimic epileptic seizures and often result in misdiagnosis as epilepsy.

 

• Dissociative seizures are involuntary and often disabling.

 

• Accurate and early diagnosis of dissociative seizures leads to more appropriate and effective healthcare resource utilization.

 

• With psychotherapy targeted towards dissociative seizures, roughly 80% of patients will have a greater than 50% reduction in seizure frequency and improvement in quality of life.

 

• Dissociative seizures should not be treated with antiseizure medications. Antiseizure medications with psychotropic effects can treat psychiatric comorbidities in patients with dissociative seizures but are not recommended as first-line.

Historical note and terminology

There is substantial debate and strong disagreement regarding the appropriate and sensitive terminology regarding patients' events. Although inappropriate and offensive terminology are widespread, their use can cause real harm to the therapeutic relationship between patient and provider, especially in the emergency setting (Robson and Lian 2017). Each of the following phrases are typically used and acceptable for clinical practice:

 

• Dissociative seizures
• Nonepileptic seizures
• Nonepileptic events
• Psychogenic seizures
• Psychogenic nonepileptic seizures
• Psychogenic nonepileptic attacks
• Psychogenic nonepileptic attack disorder
• Conversion disorder with seizures or attacks
• Functional neurologic disorder with seizures or attacks

The terminology debate focuses around both the descriptors and the noun. The term adopted by the International League Against Epilepsy (ILAE) is psychogenic nonepileptic seizures, whereas our preferred term is dissociative seizures. Some patients and a minority of providers consider “psychogenic” a pejorative term because it is connected to the stigma of psychological disease. The term “dissociative seizures” is appropriate because during events the patient's physical movements or mental status dissociates from conscious control. In cases where a psychiatric etiology is resisted, the general term “nonepileptic seizures” is acceptable.

The discussion regarding the noun balances the assumed interpretation of the word “seizure” with the nonspecific nature of the terms “attack” or “events.” Although both providers and lay public tend to understand a seizure as an epileptic seizure, the Greek word originally means “to take hold.” By removing the term “seizure,” one can clearly express that antiseizure medication should not be used to treat them. However, the patient's experience of the events is similar to seizures and untrained observers describe the events as seizures, so changing the term would constantly challenge the patient's understanding of how to describe the events and the terms “events” or “attacks” are nonspecific. Additionally, as LaFrance discussed (LaFrance 2010), many patients with dissociative seizures have been attacked physically, sexually, and emotionally (Kerr et al 2018), and the seizures are very different from these original attacks, so the term “attacks” is less desirable. Yet another alternative includes “convulsions,” which does not describe the substantial population of patients with nonmotor psychogenic nonepileptic seizures (Asadi-Pooya 2019).

The discussion regarding the descriptor focuses on choosing a term that highlights the appropriate psychiatric mechanism while not offending patients. The terms “hystericoepilepsy” and “pseudoseizure” are both offensive to patients and not appropriate descriptors because these seizures are not a subtype of epilepsy and they are not “fake” or “false” (Stone et al 2003). Instead, they are real and markedly disabling to the patient. We highly discourage use of these terms. Similarly, we highly discourage describing epileptic seizures as “true” or “real.” The ILAE adopted term of “psychogenic” is a corollary of “epileptogenic” that describes the region of the brain that is necessary and sufficient for occurrence of epileptic seizures. However, the root word of “psycho” can make the patient feel as though they are labelled as a “psycho” in lay terms, and is similar in its offensiveness to pseudoseizures in patient surveys (Stone et al 2003). “Functional” is a neutral term that does not offend, but is a code word without much meaning, and does not match the dysfunction caused by the seizures. In contrast, the terms “dissociative” and “conversion disorder” have specific definitions in psychiatry and suggest psychiatric mechanisms that have yet to be established. The ICD-10 and DSM-5 classify dissociative seizures under conversion disorder and no longer require identification of a stressor causing the events because in about 10% to 15% of patients, a stressor cannot be identified. This nosology reflects how dissociative seizures do not fit under the subtypes of dissociative disorders in the DSM-5.

The descriptor of “nonepileptic” can be used instead of or in addition to the descriptors above. In patients resistant to the stigma of psychiatric disorders, the nonspecific term “nonepileptic seizures” can maintain the therapeutic alliance while also motivating acute removal of antiepileptic medication prior to discharge from video-EEG units, which may improve future outcomes (Duncan 2006). In our opinion, nonepileptic seizures is unnecessarily vague because it does not adequately distinguish psychogenic nonepileptic seizures from physiologic nonepileptic seizures, including but not limited to convulsive syncope, complex migraines, movement disorders, parasomnias, or other paroxysmal events. Further, this equates to defining nonepileptic seizures by what they are not, which does not reflect the current understanding that functional neurologic disorders can be a positive diagnosis with clear associated factors. The concept that functional neurologic disorders is a diagnosis of exclusion may lead to delays in appropriate care and thereby worse outcomes (Kerr et al 2016).

In general, we recommend choosing the terminology that the provider feels can be understood and accepted by the patient as descriptive of their seizures. Anecdotally, some patients have felt empowered when we involved them in the decision regarding how to describe their events.

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