Dissociative Seizures
We have been seeing an increasing number of patients with dissociative seizures at Ormond Neuroscience. Alternatively, perhaps I am more aware of dissociative seizures, so I notice it more easily. Curious about the epidemiology, I investigated. Amazing figures when one investigates the epidemiology. Refractory epilepsy is epilepsy that is resistant to drug treatment. Turns out that about 20%-30% of patients diagnosed with refractory epilepsy have been misdiagnosed and do not actually have epilepsy at all. Instead, these patients have dissociative seizures, a complex and debilitating neuropsychological condition that is difficult to diagnose. On average, there is a seven year lag between onset of symptoms and diagnosis. Unfortunately, the cost of the misdiagnosis is enormous for both the patient and society.
Many patients are prescribed antiepileptic drugs (AEDs). Some may use AEDs unnecessarily for several years. The side-effects of AEDs include moderate impairment of cognitive functioning, daytime sleepiness, gingivitis, and even liver toxicity when the dosage is too high. Misdiagnosed patients are frequently absent from work and may even be unnecessarily hospitalised. Some may even be banned from driving or operating heavy machinery. Those limitations which may unfairly restrict their capacity to generate income. A minority are at risk for iatrogenic complications, such as AED toxicity or even vocal cord injury during intubation while in “status pseudo-epilepticus.”
What are Dissociative Seizures?
Dissociative seizures (aka psychogenic seizures, pseudo-seizures, nonepileptic attacks) are an unconscious and involuntary reaction to psychological stress. Approximately 10% of patients with dissociative seizures also have genuine refractory epilepsy, which complicates management and diagnosis substantially. No single sign or symptom is pathognomonic, and many differences exist between dissociative seizures and true epileptic seizures. Video electroencephalography (VEEG) is the gold standard for differential diagnosis, but is not infallible since simple partial seizures and frontal lobe seizures are not invariably accompanied by changes in the ictal scalp EEG.
Giving and Receiving the Diagnosis
Unfortunately, giving and receiving the diagnosis of dissociative seizures is hugely problematic. The psychodynamics of dissociative seizures are highly complex. Many patients don’t want to hear that psychological problems cause their seizures. They fixate on the idea that their seizures are the result of a neurological abnormality.
Indeed, for many, their lives revolve around the belief that they are suffering from epilepsy. Unwittingly, years of medical treatment reinforce the misbelief. Furthermore, finding that they have been wasting time trying different AEDs may annoy the treating neurologist.
The moment of making a diagnosis of dissociative seizures is a make or break event. When communicated carefully and skilfully, the patient accepts the diagnosis, and then seizure frequency drops by more than half. However, may patients resist the diagnosis. Within 18 months of diagnosis, an alarming 20% of patients with dissociative seizures attempt suicide. Clearly, patients with complex psychological issues may not receive this diagnosis well. It is relevant that approximately 80% of this patient group have psychiatric comorbidities.
Who should give the Diagnosis?
Ideally, a neuropsychologist should communicate the diagnosis. A neuropsychologist should understand the condition and be able to manage the psychodynamic issues at play. They will gently lead the patient to a point where they are able to understand and accept the reality of dissociative seizures and not react against the diagnosis. Normally, psychotherapy follows the diagnosis, facilitating acceptance and integration of ideas. Sometimes, aAdjunt treatment may include psychotropic medication. Please contact us if you need a neuropsychologist to assist with the management and diagnosis of dissociative seizures.
