Dissociative seizures (DS) are episodes that mimic epileptic seizures but do not originate from abnormal electrical activity in the brain. They are a manifestation of psychological distress, often classified under the broader category of Functional Neurological Disorder (FND). These events are also widely known as Psychogenic Non-Epileptic Seizures (PNES). The episodes are involuntary and genuine, representing a physical response to underlying emotional or psychological factors. Misdiagnosis can lead to incorrect and potentially harmful treatment, such as the unnecessary use of anti-epileptic medications.
Defining Characteristics of Dissociative Seizures
The observable features of a dissociative seizure event often help distinguish it from true epilepsy. A common feature is the asynchronous or irregular movement of the limbs, which often fluctuate in intensity rather than presenting the sustained, rhythmic jerking seen in generalized tonic-clonic seizures. Movements may also involve side-to-side head shaking, pelvic thrusting, or arching of the back, behaviors rarely seen in epileptic events.
The state of awareness during the episode is a key differentiator. Individuals experiencing a dissociative seizure may appear unresponsive but often maintain some level of consciousness or awareness of their surroundings. They typically exhibit eye closure during the event, a trait observed in approximately 95% of dissociative seizures, while eye opening is more typical during epileptic seizures. Dissociative seizures often have a gradual onset and can last for extended periods, sometimes much longer than the typical two-minute duration of an epileptic seizure.
The term “dissociative” refers to the psychological mechanism of temporary disconnection from immediate reality or sense of self. This psychological defense mechanism converts overwhelming emotional stress into a physical manifestation. While the behavior is involuntary, it is considered a functional problem in the brain’s signaling rather than a structural or electrical one.
Underlying Psychological Causes and Risk Factors
Dissociative seizures are rooted in psychological and emotional distress, often serving as an involuntary coping mechanism for overwhelming internal conflict. A strong association exists between DS and a history of trauma, which can include childhood physical, sexual, or emotional abuse. A history of significant trauma is present in a substantial number of patients with DS.
Not all cases are linked to past trauma; acute or chronic life stressors can also be precipitating factors. Events such as bereavement, relationship difficulties, or severe financial stress may trigger the onset of these episodes. The seizure is thought to be the physical manifestation of emotional pain that the person is unable to process or express consciously.
Individuals with dissociative seizures have a high rate of co-occurring mental health conditions. Up to 90% of those diagnosed with DS also have comorbid psychiatric disorders, often including Post-Traumatic Stress Disorder (PTSD), anxiety disorders, depression, and certain personality disorders.
Diagnosis and Differentiation from Epilepsy
Accurate diagnosis is necessary to prevent mistreatment and a delay in appropriate care. The gold standard for confirming a diagnosis of DS and ruling out neurological epilepsy is Video-Electroencephalography (V-EEG) monitoring. This test involves continuous video recording of the patient alongside an EEG, which measures the electrical activity of the brain.
During V-EEG, the video captures the physical presentation if a seizure-like event occurs, while the EEG simultaneously records the brain’s electrical signals. A diagnosis of dissociative seizures is confirmed when the patient exhibits physical symptoms of a seizure, but the EEG shows no corresponding abnormal electrical activity. In contrast, an epileptic seizure is characterized by a burst of excessive electrical discharge in the brain.
A detailed patient history, including a review of the events leading up to, during, and immediately after the episode, is an important part of the diagnostic process. Observation of the seizure’s clinical features, such as fluctuating intensity or preserved awareness, further supports the diagnosis.
Therapeutic Approaches for Management
The management of dissociative seizures focuses on treating the underlying psychological and emotional causes rather than the physical symptoms. Since the episodes are not caused by abnormal brain electricity, anti-epileptic medications are ineffective and should be gradually withdrawn once the correct diagnosis is made. The primary approach for long-term reduction in seizure frequency is psychotherapy.
Cognitive Behavioral Therapy (CBT) is one of the most effective psychotherapeutic interventions for DS. CBT helps individuals identify and modify the thought patterns and behaviors that contribute to their distress, teaching them new coping strategies for emotional triggers. Trauma-focused therapies are also utilized, particularly when a history of abuse or PTSD is present.
Patient education is a component of treatment, as understanding the diagnosis helps the individual develop a non-epileptic model for their symptoms. Psychiatric support may also be provided to manage co-occurring conditions like anxiety or depression, sometimes involving psychoactive medications, which are used to treat the underlying mood disorder, not the seizures themselves. This comprehensive approach has been shown to reduce seizure frequency significantly in a majority of patients.